Every finding on record at Willow Ridge Healthcare

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 26 residents residing in the facility.Surveyor observed a scoop left in the flour storage bin.Missed opportunities for litmus testing of sanitation solution (red bucket) in cook's area. Logs for sanitizer bucket Parts Per Million (PPM) and sanitization levels were not completed.Findings include:Example 1The facility policy, title Food Storage Standards, states:3. Criteria for Dry Food Storage.f. Working containers holding dry food or ingredients that are removed from their original packages are identified with the common name of the food, unless the food is easily recognizable such as pasta.g. Staff receives training on the proper dry food storage.4. Quality Assurance:d. Training records are evaluated to make sure all dietary employees have received training in the proper storage of foods; training records are maintained. On 7/29/25 at 11:32 AM, Surveyor observed the kitchen and meal service. [NAME] O showed Surveyor where the flour and sugar were kept. [NAME] O opened both bins for Surveyor to observe, as scoop was in the sugar. [NAME] O did not remove it. Surveyor interviewed [NAME] O. [NAME] O stated that training is completed on the CE Solutions, it includes food safety and handling. On 7/29/2 at 11:32 AM, Surveyor interviewed [NAME] K who stated that scoops and items are not left to be used later. The 3-compartment sink is used to clean large pots, and smaller items are sent back to the dishwasher.On 7/30/25 at 8:34 AM, Surveyor interviewed Dietary Manager (DM) N who stated flour and sugar are kept in large bins right by mixer. DM N stated that she does the refilling of bins. DM N lets them get almost empty, dumps out and washes out the bin, lets dry completely, refills, and labels what it is and date with masking tape. DM N stated that scoops are always cleaned and kept right by the bins. Use it and put the scoop in back to go through a dishwasher. Surveyor asked DM N to observe the bins with Surveyor. DM N opened the sugar and looked at Surveyor, They left a scoop, that should not be in there. I can't believe they did that. Surveyor and DM N discussed training logs and expectations. CE Solutions is used for training and where logs are kept.Example 2 Sanitizing SolutionNo facility policy for review.FDA Food Code, 2022 at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness indicated: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions.FDA Food Code, 2022 at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.Surveyor reviewed the facility log, titled Litmus Testing- Bucket System (Red Bucket) reviewed. The top of the log has spot for month and year, directions to see Quaternary Test Poster, record results below, Dash specs if not used. The bottom of the log states [NAME] Range PPM: 150 to 400 PPM. If out of range, you must either contact maintenance or the dietary director and documented (date/initial) by temperature that you have done so. The log has columns for the date, time, temp, PPM and staff initials. In April 2025 there were 30 days and 90 opportunities to test PPM, there were 17 opportunities missed: 4/2 PM, 4/6 PM, 4/8 PM, 4/16 AM, Noon and PM, 4/18 PM, 4/19 PM, 4/20 PM, 4/21 Noon and PM, 4/22 PM,4/24 PM, 4/25 Noon and PM, 4/30 Noon and PM. 24 PPM measurements were out of range and unclear if followed up on. There are initials in the same column for dates in range and out of range. In May unclear testing continues; there are no dates where testing PPM was missed but 30 tests were out of range and unclear if followed up on. There are initials in the same column for dates in range and out of range. In June 2025, there were 30 days and 90 opportunities to test PPM or for PPM to be out of range, 2 opportunities were missed: 6/14, 6/26 and 10 PPM testing that are out of range and unclear if followed up on. There are initials in the same column for dates in range and out of range. In July 2025, there have been 28 full days of meals before Surveyor entered the kitchen or 75 opportunities to test PPM: 7/5 AM, 7/7 noon and PM, 7/16 AM, 7/19 AM, 7/28 noon and PMOn 7/29/25 at 10:20 AM, Surveyor interviewed DM N regarding requirements for monitoring sanitizing solution ppm and concentration. DM N stated there is a log and staff do it at every meal. DM N pulled up computer and attempted to find a policy. Policy was not found and one was not brought forward at a later time. On 7/29/25 at 11:32 AM, Surveyor interviewed [NAME] K and [NAME] O. [NAME] K stated the red bucket kept by the 3 compartment sink is the cook's sanitizing solution. Solution is made each meal and as needed. [NAME] O stated it was cook's responsibility to check the PPM level and record it on the log. [NAME] N showed Surveyor where the strips were kept. [NAME] K stated we let DM N know whenever we need something or there is a problem.On 7/30/25 at 10:40 AM, Surveyor interviewed DM N to clarify what it means when spots are scribbled out. DM N stated, I don't know what is going on there. I guess it was a missed test.

Based on interview and record review, the facility did not ensure that 1 of 8 employees were screened for a history of abuse, neglect, exploitation, or misappropriation of resident property to prohibit abuse, neglect, and exploitation of resident property, as state and federal regulations require. -Facility did not screen Registered Nurse (RN) H for an out of state Background Information Disclosure (BID) when hired. Findings include:Surveyor reviewed facility policy titled, Resident Safety Abuse Policy, dated revised on 02/2022, stated in part: .#3. a. Employee Screening:i. All individuals considered for employment shall receive a reference check. All responses shall be documented. The reference sources shall be asked about job performance, skills, habits, and reliability.ii. All employees shall have a criminal background check.1. Initial and any required future background checks will be conducted in accordance with applicable state and federal laws. Checks may include criminal history, state caregiver registry, OIG, and exclusion lists. The type frequency, and timing of checks will be in accordance with applicable state and federal law . Surveyor reviewed background checks. RN H filled out BID on 07/08/24. RN H answered question #4 that RN H lived in Minnesota in the last 3 years. Facility did not run a background for Minnesota. The BID was run for RN H on 08/27/24 through Wisconsin database but not Minnesota. On 07/29/25 at 10:01 AM, Surveyor interviewed Business Office Manager (BOM) E and asked about the missing Minnesota background check for RN H. BOM E reported to Surveyor that BOM E is unsure how that got missed. Usually, corporate will let BOM E know when to run an out of state background check. BOM E reported the facility will start running it now. BOM E reported to Surveyor that RN H does not have the background complete, and it was not completed prior to Surveyors' arrival to facility for this survey.

Based on interview and record review, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice for 1 out of 12 residents (R) reviewed, R14.Facility staff did not follow R14's physician orders for administration of insulin.This is evidenced by: R14 was admitted to the facility on [DATE]. R14's current diagnoses include type 2 diabetes mellitus, vascular dementia, and adult failure to thrive. R14's cognition is moderately impaired and requires staff supervision when eating. Review of R14's physician medication orders documented in part. 03/05/24 Insulin Glargine 22 units daily in AM, FOR: type 2 diabetes mellitus.04/9/24 Insulin Lispro 8 unit twice a day at Breakfast and Midday (Lunch) HOLD if meal intake is less than 25%, FOR type 2 diabetes mellitus.04/9/24 Insulin Lispro 6 units daily at Supper. HOLD if meal intake is less than 25%, FOR: type 2 diabetes mellitus.11/12/24 Blood sugar check: Blood Glucose Checks twice a day pattern: Monday Wednesday Friday Sunday 0800 and 1600. Notify physician if blood sugar < 70 if symptomatic and protocol treatment fails. Notify physician if blood sugar > 400 x 2 or if symptomatic for hyperglycemia/hypoglycemia.11/12/24 Blood sugar check: twice a day Tuesday, Thursday, Saturday 1200 and 2000 (diabetes). Notify physician if blood sugar < 70 if symptomatic and protocol treatment fails. Notify physician if blood sugar > 400 x 2 or if symptomatic for hyperglycemia/hypoglycemia.Review of meal intake charting for 06/12/25 documented R14 refused breakfast. The medication administration record (MAR) documented on 06/12/25 at 9:39 AM Insulin Lispro 8 units was administered to R14.Review of meal intake charting for 07/09/25 documented R14 refused lunch. The MAR documented on 07/09/25 at 1:15 PM Insulin Lispro 8 units was administered to R14.Review of meal intake charting for 07/15/25 documented R14 refused supper. The MAR documented on 07/15/25 at 6:30 PM Insulin Lispro 6 units was administered to R14. On 07/30/25 at 5:46 PM, Surveyor interviewed Quality Consultant Register Nurse (RN) G about the times R14 had no meal intakes and insulin Lispro was given, against the physician orders. RN G stated the physician order was not followed. RN G will clarify the order with the physician.

Based on observation, interview and record review, the facility did not develop and implement a comprehensive care plan for each resident (R) to meet medical, nursing, and psychosocial needs identified for 2 of 12 sampled residents (R0 (R3 and R8).R3 and R8 did not have a sleep hygiene care plan developed when prescribed medication to promote sleep.This is evidenced by:Example 1R3 was admitted to the facility on [DATE]. R3's current diagnoses include in part, cerebral infarction, type 2 diabetes mellitus, anxiety, aphasia, hemiplegia right dominant side, narcolepsy, and atrial fibrillation.R3's physician orders documented an order on 03/01/25 to give melatonin 5 mg by mouth daily HS (bedtime) for insomnia.On 06/26/25, a sleep assessment was completed documenting R3 on average sleeps 7-8 hours with a goal of 8 hours and try to avoid excess fluid intake. Review of R3's care plans did not document a sleep hygiene care plan was developed with non-pharmacological interventions to promote sleep. Example 2R8 was admitted to the facility on [DATE]. R8's current diagnoses include in part, encephalopathy, weakness, Alzheimer's disease with late onset, depression, anxiety disorder, and chronic kidney disease stage 3b. R8's physician orders documented orders on 07/03/23 melatonin 3 mg tablet dose by mouth daily prn insomnia and 09/29/23 melatonin 5 mg tablet dose by mouth daily PM insomnia. On 07/30/25 at 11:23 AM, Surveyor interviewed Quality Consultant Registered Nurse (RN) G about R3 and R8's sleep hygiene care plans for use of melatonin. RN G stated there was not a care plan developed for sleep for R3 and R8, and a care plan is entered now.

Based on observation, interview and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) (R4) received care consistent with professional standards of practice to prevent the development of a new pressure injury and did not ensure the plan of care was consistently followed for R4, who is at risk for pressure injuries. R4 was at risk for PI development. R4 had an area of concern on right heel. The facility failed to provide adequate and consistent repositioning to off load R4's heels and buttock. This is evidenced by:Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 31, July 2025, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Turn and reposition all individuals at risk for pressure injury, turn the individual into a 30-degree side-lying position and use your hand to determine if the sacrum is off the bed, ensure that the heels are free from the bed, use heel offloading devices for high-risk pressure injuries.Surveyor reviewed Manufacturing instructions for NyOrtho Zero-G Boot, dated 2023, which stated in part, .How to measure NyOrtho Zero-G boot.-To choose the correct size measure the circumference of the lower part of the calf muscle.Model:-9518-S Small 5-10inches Petite-9518-M Medium 11-20inches Adult-9518-L Large 21-25inches Bariatric.Surveyor reviewed facility protocol titled, Skin Treatment Management and Guidelines dated last revised on 06/2023, which stated in part, .Deep Tissue Pressure Injury: Intact or no intact skin with localized area of non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing dark wound bed or blood-filled blister. Pain and temperature change precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. Support interventions for DTPIs:-Support surface/seating system-Turning and repositioning-Heel off-loading-Nutritional Support-Pain management.R4 was admitted to the facility on [DATE] with diagnoses including, in part, unspecified dementia, anemia, hypertension, benign prostatic hyperplasia, Diabetic Mellitus, hyponatremia, hyperlipidemia, depression, and glaucoma.R4's Minimum Data Set (MDS) assessment, dated 07/02/25, identified R4 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R4 was determined to be at risk for PIs and previous MDS dated [DATE] indicated R4 had multiple stage 2 PIs and 2 unstageable PIs that are now healed.Surveyor reviewed R4's Pressure Injury Care Plan dated 07/28/25:- On 07/08/25 skin care: Lotion with cares, barrier cream with all peri care/incontinence cares, be sure blankets are over bed cradle to protect toes. Resident has area of concern on right heel. Position and float right heel on pillows off bed surface. Padding to be placed on the end of resident bed for extra cushion.-On 07/28/25, Nurses to assess skin status, keep provider informed, administer analgesics as ordered, and follow medical plan for treatment.- On 07/28/25, Nurse aide to keep skin clean and dry, encourage and assist to reposition. Inspect skin every shift and report changes. - On 07/28/25, Turning/repositioning assist of 2. R4 will need to be laid down following breakfast and lunch. Use slip sheet for repositioning, reposition every 1 hour and as needed to relieve pain while in bed or in wheelchair, be sure to position pillows on alternating sides for pressure relief on buttock. Ensure proper placement of feet in bed, drape a blanket over footboard for additional padding. Surveyor reviewed physician orders which include:.-On 09/20/23-Cradle on resident bed, resident to wear blue boots while in bed and foam heel protector on right foot at all times when up.-On 09/20/23-Resident to lay down following breakfast and lunch to off load.-06/25/25-Cleanse 3rd toe with wound cleanser, paint iodine and cover with band aide daily.-On 07/09/25-Monitor for skin integrity changed of feet and foam boots, Prevalon always boots both foot/feet daily.-On 07/17/25- Apply Meplix bordered foam or equal to right buttock. Do not use cornstarch.-On 07/22/25- Reposition every hour.Surveyor reviewed R4's progress notesOn 07/28/25 at 1:45 PM, Surveyor observed nursing students transfer R4 to bed. Surveyor observed nursing students exit room. Surveyor looked in R4's room and observed R4 lying on left side in bed. Surveyor observed R4's heels have Nyortho Zero-G boots on, blanket was lying on top of R4's toes and R4's heels were touching flat on bed. Surveyor did not observe R4's heels floated to decrease pressure and off load R4's heels while lying in bed. Surveyor did not observe R4's blanket draped over foot guard to protect R4's toes from pressure.On 07/29/25 at 7:55 AM, Surveyor observed nursing student getting R4 up for breakfast. R4s heels have Nyortho Zero-G boots on, blanket was lying on top of R4's toes and R4's heels were touching flat on bed.Surveyor did not observe R4's heels floated to decrease pressure and off load R4's heels while lying in bed. Surveyor did not observe R4's blanket draped over foot guard to protect R4's toes from pressure.On 07/29/25 at 8:05 AM, Surveyor observed nursing student bring R4 down to dining room for breakfast.Continuous observation from 9:01 AM -11:14 AM:On 07/29/25 at 9:01 AM, Surveyor observed R4 lying back in bed after breakfast on back. Surveyor observed R4's heels have Nyortho Zero-G boots on, blanket was lying on top of R4's toes and R4's heels were touching flat on bed. Surveyor did not observe R4's heels floated to decrease pressure and off load R4's heels while lying in bed. Surveyor did not observe R4's blanket draped over foot guard to protect R4's toes from pressure.On 07/29/25 at 10:59 AM, Surveyor observed R4 lying on back in bed. Surveyor observed R4's heels have Nyortho Zero-G boots on, blanket was lying on top of R4's toes and R4's heels were touching flat on bed.On 07/30/2025 at 11:14 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F and asked CNA F if CNA F knows what size R4's Nyortho Zero-G boots are. CNA F reported to Surveyor that CNA F is unsure about the Nyortho Zero-G boot. Surveyor asked CNA F how CNA F knows what size Nyortho Zero-G boot to utilize once Nyortho Zero-G boots are ordered for residents. CNA F reported to Surveyor that CNA F did not know there are different sizes. Surveyor asked CNA F to enter R4's room together to assess R4's Nyortho Zero-G boots and position of R4. CNA F reported to Surveyor that R4's feet should be elevated, and CNA F observed R4's bilateral heels touching flat on bed surface. Surveyor asked CNA F if CNA F could place hand under R4's feet and let Surveyor know if R4's heels are touching bed surface. CNA F reported that R4's bilateral heels were in fact touching the bed surface through the Nyortho Zero-G boots. Surveyor asked CNA F to peek at the size of R4's Nyortho Zero-G boots. CNA F reported to Surveyor that R4's Nyortho Zero-G boots are size large bariatric size on the tag. Surveyor asked CNA F if it is still CNA's duty to check after nursing students to make sure R4 is receiving the correct care for repositioning per R4's care plan. CNA F reported to Surveyor that CNAs should still be following R4's care plan and checking to make sure it is completed but sometimes nursing instructor does not make it easy for regular staff to complete staff's duties if nursing students have certain residents. Surveyor asked CNA F if R4's blanket is supposed to be draped over foot guard to prevent pressure on R4's toes. CNA F reported to Surveyor that R4's blanket should not be lying on top of R4's toes. CNA F repositioned R4 and laid blanket off R4's toes and unto the foot guard. On 07/30/2025 at 11:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C and asked RN if R4 is supposed to have a Meplix on R4's right buttock. LPN C reported to Surveyor after looking in R4's physician orders that R4 is to have Meplix on right buttock to protect recent breakdown from discovery on 07/17/25. Surveyor asked LPN C if LPN C placed a Meplix on R4 yesterday 07/29/25 or today on 07/30/25. LPN C reported to Surveyor that LPN C did not place a Meplix on R4 because staff have not reported to LPN C that R4 needs it on R4's buttock. LPN C reported that today was R4's shower day. Surveyor asked LPN C to enter R4's room and observe if Meplix was on R4's right buttock. On 07/30/2025 at 11:33 AM, Surveyor observed LPN C enter R4's room and completed hand hygiene. LPN C then had nursing students roll R4 unto left side, and LPN C noted there was not a Meplix to R4's buttock area on right side. LPN C cleansed area and stated, Right buttocks slightly red in this area, I will place a Meplix. Surveyor observed LPN C place Meplix on R4's right buttock. On 07/30/25 at 12:16 PM, Surveyor interviewed Regional Corporate RN G and asked if RN G, Director of Nursing (DON) B, and Surveyor could go correctly measure R4's boot for proper measurement. RN G reported to Surveyor that once R4 is out of dining room for lunch that RN G, DON B, and Surveyor can enter R4's room to measure calf. On 07/30/25 at 1:32 PM, Surveyor asked DON B and RN G to measure mid-calf for correct measurements of Nyortho Zero-G boot utilized to prevent pressure for R4. RN G measured calf and noted it was 12 inches in circumference. DON B and RN G reported to Surveyor that R4 is wearing incorrect boot sizes and needs to be a medium size instead of a large size.On 07/30/25 at 1:35 PM, Surveyor interviewed DON B and asked DON B's expectation for R4's intervention to relieve pressure due to R4's at risk for skin breakdown, past PIs, and current concern for R4's right heel. Surveyor reported to DON B that for the last 3-day observation of R4's repositioning and cares, Surveyor observed R4 not being repositioned every hour as care plans states, and R4's feet were not elevated with blanket over foot guard to prevent further pressure from occurring. DON B reported to Surveyor that expectation would be that staff are still responsible for R4 even if nursing students are providing the care and staff should have made sure that R4's heels and toes are relieved from pressure. Surveyor reported to DON B that R4's boots are incorrect size. Surveyor asked DON B who is responsible for measuring the boots appropriately. DON B stated, I guess that is the wound care nurse's job when ordering boots. Surveyor asked DON B if wound care nurse measured R4's boots. DON B stated, Obviously not because he has the wrong size boots on. Surveyor asked DON B where documentation for R4's right heel and toes assessments were as the notes were not given to Surveyor after requesting. DON B reported to Surveyor that R4 does not have any PI injuries. Surveyor reported to DON B that through documentation Surveyor reviewed it is noted that R4 has had multiple Deep Tissue Injury (DTI) to toes bilaterally and on right heel. DON B reported to Surveyor that R4's DTIs are not pressure related. Surveyor explained to DON B the definition of a DTI. DON B reported to Surveyor that DON B does not acknowledge that a DTI is a pressure injury. Surveyor asked DON B what resources DON B utilizes to define DTI and what guidelines do you follow. DON B reported to Surveyor that DON B utilizes the NPIAP guidelines for wound management along with facility protocol on wound management.On 07/30/25 at 2:21 PM, Surveyor interviewed DON B with RN G and NHA A present in DON B's office. Surveyor asked DON B, since DON B does not acknowledge that a DTI is considered a PI, then what resource does DON B utilize to assess and treat PIs. DON B reported to Surveyor that DON B in the wound care class that DON B took it never discussed a DTI as a PI. DON B reported to Surveyor that DON B utilizes the wound care protocol of the facility. Surveyor requested a copy of the Wound Care protocol. Surveyor asked DON B and RN G if one could follow Surveyor into R4's room to observe R4's position and heels. RN G and NHA A offered to assist Surveyor. On 07/30/25 at 2:25 PM, Surveyor, RN G and NHA A entered R4's room and observed R4 lying on back in bed. Surveyor, RN G and NHA A observed R4's heels have Nyortho Zero-G boots on, blanket was lying on top of R4's toes and R4's heels were touching flat on bed. RN G immediately repositioned R4's feet to float heels by placing pillow under R4. RN G took R4's boots off to examine and assess R4's heels bilaterally. Surveyor observed left heel intact and no concerns. Surveyor and RN G assessed R4's right heel. RN G stated, Still blanchable but I do feel some bogginess, and I see peeling of skin on right heel, could be dry skin but at this point I will document this as a finding of an area of concern.

Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not ensure staff followed transfer precautions and supervision when needed to prevent accidents which effected 1 of 4 residents (R2) reviewed for falls. -Certified Nurse Assistant (CNA) D transferred R2 from wheelchair to bed without gait belt in place during transfer process.Findings include:R2 was admitted to the facility on [DATE] with diagnoses including, in part, right above the knee amputation, unspecified dementia, Huntington's disease, chorea, neurocognitive disorder, heart valve replacement, and depression.R2's Minimum Data Set (MDS) assessment, dated 07/17/25, identified R2 required partial to moderate assistance with transferring and R2 has a lower impairment to one side. Surveyor reviewed R2s care plan:-Assist of 2 for transfers with gait belt, not appropriate prosthetic leg. Locomotion in wheelchair.On 07/29/25 at 9:51 AM, Surveyor observed CNA D and CNA F enter R2's room. CNA D applied gloves and began prepping R2's bed to transfer R2 into bed. Surveyor observed CNA D hug R2 and instruct R2 to hug CNA D back. CNA D stood R2 and pivoted R2 on one leg to bed. CNA D sat R2 down on edge of bed. CNA F stood behind R2's wheelchair and stated, Oh she is still on edge of bed, be careful. CNA D quickly boosted R2 back into bed further before letting go of R2. Surveyor did not observe CNA D utilize gait belt during R2's transfer. Surveyor also observed right side of R2's wheelchair was not locked upon the stand pivot transfer. On 07/29/25 at 1:35 PM, Surveyor observed CNA D and CNA F place R2 down in bed. CNA D and CNA F used a stand pivot transfer to place R2 in bed. Surveyor did not observe CNA D and CNA F utilize a gait belt during R2's stand pivot transfer.On 07/29/25 at 1:45 PM, Surveyor interviewed CNA D and asked what CNA D's correct process for transfers with R2 is. CNA D reported to Surveyor that with R2 it is care planned that staff does not use a gait belt during transfers with R2 since R2 is on anticoagulants. Surveyor reviewed care plan and could not find that R2 is not to use a gait belt during R2's transfers. On 07/30/25 at 5:35 PM, Surveyor interviewed Regional Corporate RN G and asked what is R2's care plan for transfers. RN G reported to Surveyor that R2 is assist of 2 with gait belt. Surveyor reported to RN G the observation of CNAs stand pivot transferring R2 to bed from wheelchair. RN G reported that CNAs should have used gait belt and assist of 2 to transfer due to R2 being at risk for falls from R2 flailing around and sometimes hard to transfer.

Based on record review and interview, the facility did not ensure that 1 of 1 resident (R) reviewed received appropriate respiratory care during administration of respiratory treatments (R5). This is evidenced by:The facility procedure Using Small Volume Nebulizers, from book titled Clinical Nursing Skills and Techniques 11th edition, by [NAME] which states: Assessment6. Perform hand hygiene. Assess pulse, respirations, breath sounds, pulse oximetry, and peak flow meter (if ordered) before beginning treatment. Implementation12. Rinse nebulizer cup per agency policy.R5 was admitted to the facility on [DATE] and has diagnoses that include tetralogy of fallot, COPD, acute respiratory failure with hypoxia, macrocephaly, disturbances of salivary secretion, anxiety disorder and persistent mood affective disorder.R5's Minimum Data Set (MDS) assessment, completed on 5/29/25, confirmed R5 has poor hearing and no speech and does not understand and rarely is understood. R5 is unable to make decisions due to her cognitive skills and is dependent for mobility, transfers and all cares.R5's physician orders include Albuterol Sulfate 2.5mg/3ml, Budesonide 0.25mg/2ml suspension inhalation twice a day. Apply vest therapy for 15 minutes during nebulizer treatments BID. (Vest therapy refers to a vest patients wear that applies mild vibration to break up respiratory secretions caught in the lungs.)R5's care plan, dated 6/24/25, states: Monitor breathing, neuro status and vitals, prevent obstruction of air way by elevating head of bed 30 degreesOn 7/28/25 at 4:34 PM, Surveyor observed Nurse Tech (NT) J administer R5's Albuterol nebulizer treatment followed by a Budesonide nebulizer treatment. Respiratory treatments were done at the same time as caring for tube feeding. At beginning of the cares, NT J used clean technique to assemble the nebulizer equipment, placed Albuterol nebulizer solution in cup, attached it to the mask, applied the mask to R5 and started the machine and treatment.At this point the Albuterol nebulizer was completed. NT J set up and started the Bedesonide nebulizer. The vest turned off at 15-minute mark and shortly after the second nebulizer treatment was done. NT J took off nebulizer mask and vest and put aside. NT J stated NT J was behind so NT J will clean this later. NT J stated NT J will rinse it before R5's next nebulizer at 8:30. We clean set ups once a shift. NT J did not assess lung sounds or do an oximetry prior to the updraft between, or after nebulizer treatment. On 07/30/25 at 1:43 PM, Surveyor interviewed Licensed Practical Nurse (LPN) I, who stated that assessment of lung sounds should be done before you start a nebulizer treatment.On 07/30/25 at 1:43 PM, Surveyor interviewed Director of Nursing (DON) B who stated DON B expects lung sounds to be assessed prior to nebulizer treatment. Surveyor asked DON B about cleaning of nebulizer supplies. DON B stated they are cleaned once a shift and at least rinsed in-between uses. On 07/30/25 at 4:09 PM Surveyor followed up with DON B about policies related to lung assessment before nebulizer treatment. DON B stated I don't have one right now, that's standard procedure.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases and infection. Licensed Practical Nurse (LPN) M observed administering medication for 2 consecutive hours with improper hand hygiene opportunities for 4 of 4 residents observed. (R11, R18, R19, R22).Staff did not wear appropriate PPE for cares with R5 and R1.Staff did not perform hand hygiene when needed during cares for R14.Findings include: Example 1 The facility policy, titled Standard and Transmission-Based Precautions, dated 1/2025, states: 1. Hand Hygiene: a. Hand hygiene refers to hand washing with soap and water OR using alcohol-based hand rubs (gels, foams, rinsed) that do not required access to water. Policy attachment, titled Hand Hygiene: Why, How, & When? states: When? Your 5 Moments for Hand Hygiene 1. Before touching a patient . 2. Before Clean/Aseptic Procedure. d) Before Preparing food, medications. On 7/29/25 at 7:04 AM, Surveyor observed LPN M return to the cart with garbage in her hand when Surveyor was waiting to start observing medication pass. Surveyor observed LPN M throw the garbage in her hand away, lifted the screen and found her next patient on the computer. LPN M opened medication cart, pulled a medication cup and started pulling and preparing medication for R22. No hand hygiene was observed. When LPN M had medication ready, LPN M lowered computer screen, locked cart and took medication to R22 who was sitting on other side of nurse's desk. Medication was administered to R22. LPN M came back to medication cart, threw garbage away, and started to push medication cart towards hallway. No hand hygiene was observed. On 7/29/25 at 7:10 AM, Surveyor observed LPN M prep medication for R19. No hand hygiene before prep and after pushing medication cart down the hall. Medication prepped, taken to administer to R19, administered medication and came back to medication cart. No hand hygiene before entering or leaving R19's room. LPN M did wipe hands with a sanitary towelette when returning to medication cart. Surveyor noticed wipes on cart from the beginning; this was the first time LPN M used them. On 7/29/25 at 7:16 AM, Surveyor observed LPN M prep medication for R18. Medication taken to room for administration. No hand hygiene leaving the cart, going into R18's room or when leaving the room. On 7/29/25 at 8:02 AM, Surveyor observed LPN M prep medications for R11. Still no hand hygiene since beginning of the last medication pass. R11's medications were prepped, taken to R11's room. No hand hygiene before entering R11's room. LPN M gave medications to R11, no hand hygiene, put on gloves, placed eyedrops, with same gloves on and rubbed Lidocaine on R11's neck. LPN M took off gloves and washed hands in R11's sink, left room and went back to medication cart and prepped next resident's medication. On 7/29/25 at 1:20 PM, Surveyor interviewed LPN M who stated hand hygiene anytime you touch patients. Alcohol gel bothers me, I use wipes. On 7/30/25 at 1:15 PM, Surveyor interviewed LPN I, who stated hand hygiene should be performed anytime you work with a patient. LPN I stated, Yes medication administration you should wash hands before and after you are with patients. On 7/30/25 at 1:52 PM, Surveyor interviewed Director of Nursing (DON) B, who stated hand hygiene should occur anytime there is interaction with patients before and after. When asked for clarification, DON B stated yes, hand hygiene should occur taking blood pressures, preparing and passing medications, and assisting residents with eating. Example 2 The facility policy, titled Standard and Transmission-Based Precautions, reviewed 1/25, states: 11. Enhanced [NAME] Precautions. a. When required, Enhanced [NAME] precautions are used IN ADDITION to Standard Precautious. ii. Enhanced Barrier Precautions expands the use of PPE (personal protective equipment) and refer to the use of gown and gloves during high contact resident care activities. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents. 1. Examples of high contact resident care actives requiring gown and glove use for enhanced barrier precautions include: f. Device care of use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. R5 was admitted to the facility on [DATE], and has diagnoses that include tetralogy of fallot, COPD, acute respiratory failure with hypoxia, macrocephaly, disturbances of salivary secretion, anxiety disorder and persistent mood affective disorder. R5 is a resident on enhanced barrier precautions (EBP) due to R5's health conditions and being on tube feedings. On 7/28/25 at 4:34 PM, Surveyor observed Nurse Tech (NT) J administer R5's tube feeding. NT J did not wear a gown during the tube feeding administrations. On 7/29/25 and 7/30/25, NT J not available to complete interview. On 7/30/25 at 1:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN) I. Surveyor asked what kind of personal protective equipment (PPE) should be used when providing or administering a tube feeding. LPN I stated both gown and gloves, maybe a mask. On 07/30/25 at 1:43 PM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for infection control measures and PPE use while administering tube feeding. DON B indicated the expectation is that staff use good hand hygiene and utilize the PPE. DON B stated tube feeding residents are on EBP which includes gloves and gowns. Surveyor indicated that NT J was not observed wearing a gown while administering tube feeding. DON B stated NT J should have had a gown on. Example 3 Surveyor reviewed facility policy titled, Standard and Transmission-Based Precautions, dated revised on 02/2024, which stated in part, .Protocol: 1. Hand hygiene: d. Perform hand hygiene after removing gloves. 2. Gloves: d. Change gloves, as necessary, during the care of a resident to prevent cross contamination from one body site to another. f. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces- and wash hands immediately to avoid transfer of microorganisms to other residents or environment. 11. Enhanced Barrier Precautions: ii. EBP expands the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Examples of high-contact resident care activities are c. transferring, d. provide hygiene, and f. assisting with toileting. On 07/29/25 at 10:11 AM, Surveyor observed Certified Nursing Assistant (CNA) D and CNA F go into R1's room to transfer with EZ-Stand. CNA D and CNA F donned PPE appropriately. CNA D and CNA F hooked R1 up to EZ-Stand and lifted R1 up into the air. CNA D and CNA F placed R1 in the bathroom on toilet to use the restroom. CNA F stated, Ok I will set the timer and come back. CNA D and CNA F exited R1's room. On 07/29/25 at 10:22 AM, Surveyor observed CNA F go into R1's room to check on R1 in bathroom. CNA F decided to sit with R1 in bathroom and cleanse R1's nails. Surveyor observed CNA F squat and start cleaning underneath R1's nails getting debris and gunk from underneath R1's nails. CNA F stated, I know I should have PPE gown on. Surveyor observed CNA F continue cleaning out R1's nails without applying a gown. CNA F stood up and leaned over the EZ-Stand machine to clean R1's left hand fingernails out. Surveyor observed CNA F's scrubs touching EZ-Stand while R1 was sitting in the bathroom on toilet. CNA F finished cleaning R1's nails, washed hands, and exited room. On 07/29/25 at 10:38 AM, Surveyor observed CNA D and CNA F go into R1's room to get R1 off toilet. CNA D and CNA F donned PPE. Surveyor observed CNA D cleanse R1's bottom. CNA D stated, R1 is smearing so I need some extra wipes. Surveyor observed CNA D cleanse R1's bottom with wipes then CNA D grabbed unto EZ-Stand and helped CNA F push wheelchair to the side and EZ-Stand back out of bathroom with same contaminated gloves on. Surveyor observed CNA F push R1 in EZ-Stand with contaminated gloves until R1 reached the main area in room. CNA F then changed gloves once R1 was in main room near recliner. CNA F unhooked R1 from EZ-Stand and then parked EZ-Stand near R1's door. CNA D changed gloves and then began completing catheter care with emptying into graduate. CNA D cleansed tip of catheter drainage and then drained catheter into graduate. Surveyor did not observe CNA D sanitize hands between glove changes. Surveyor observed CNA F take EZ-Stand out of room and cleansed the EZ-Stand with wipe. Surveyor did not observe CNA F wipe down EZ-Stand sling. On 07/29/25 at 10:56AM, Surveyor interviewed CNA D and asked CNA D if CNA D and CNA F utilize the EZ-Stand for just R1 or is the EZ-Stand utilized between other residents. CNA D reported to Surveyor that CNA D uses the same EZ-Stand lift for all residents, but the lift is wiped down good. Surveyor indicated to CNA D that Surveyor observed CNA F wipe down the whole lift but not the sling that was used with R1 during toileting. CNA D reported to Surveyor that CNA D was taught by staff that the EZ-Stand sling can be used for all residents, so CNA D did not realize it was not ok. On 07/29/25 at 11:32 AM, Surveyor interviewed CNA D and asked about hand hygiene between glove changes. CNA D reported to Surveyor that CNA D should have sanitized hands in between glove changes from cleaning bowel movement off R1's bottom before changing gloves to perform catheter care. On 07/29/25 at 11:24 AM, Surveyor observed nursing student take contaminated EZ-Stand into R7's room to transfer R7. Surveyor did not observe sling to EZ-Stand be removed or sanitized. On 07/30/25 at 5:35 PM, Surveyor interviewed DON B and asked DON B what the expectation is of hand hygiene practices between glove changes. DON B reported to Surveyor that CNA D came to DON B and told DON B the issues with hand hygiene. DON B reported to Surveyor that DON B's expectation is that all staff complete hand hygiene such as sanitizing hands or washing hands if visibly soiled between glove changes. Surveyor asked DON B's expectation of CNA F wearing PPE in EBP room. DON B reported that in R1's room R1 is on EBP for Suprapubic catheter and with high touch cares. CNA F should have been wearing PPE. Surveyor asked DON B about the use of EZ-Stand sling with all residents. DON B reported that all slings should be wiped down before utilizing for other residents especially after an Enhanced Barrier Precaution (EBP) room. Example 4 R14 was admitted to the facility on [DATE] with current diagnosis of vascular dementia. R14's cognition is moderately impaired and requires maximum staff assistance for personal hygiene. On 07/29/25 at 9:28 AM, Surveyor observed Certified Nursing Assistant (CNA) G provide R14 personal cares. CNA G applied gloves, rolled R14 and pulled down pants. CNA G removed gloves and gathered a brief. CNA G washed hands appropriately and left room to gather cleansing wipes. CNA G returned applied gloves and removed R14's incontinence brief. CNA G used cleansing wipes to clean peri area. CNA G rolled R14 to the side and cleansed buttocks with the wipes. CNA G removed gloves, did not sanitize hands and applied clean gloves. CNA G applied a clean brief to R14, covered R14 with a blanket and attached the call light to R14. CNA G removed gloves, exited room and sanitized hands. On 07/29/25 at 11:32 AM, Surveyor interviewed CNA G about hand hygiene with glove change when providing R14 personal cares. CNA G stated she did not complete hand sanitization when she changed gloves. On 07/30/25 at 5:35 PM, Surveyor reviewed with DON B Surveyor's observation CNA G providing personal cares and no hand hygiene between glove changes.

Based on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 1 of 3 residents (R) reviewed (R1). This is evidenced by: Facility's policy titled, Resident Safety Abuse Policy, revised date 02/2022, read in part: 8. Reporting Suspected Violations: a. the supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator. The Administrator will notify the DON (Director of Nursing) and/or others as appropriate. b. The administrator will report a reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from the facility, to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located. c. The administrator shall report immediately, but not later than 2 hours after forming the suspicion . R1 was admitted to the facility on [DATE]. R1's current diagnoses include athetoid cerebral palsy, dementia with moderate agitation, pain in right arm, mild cognitive impairment, restlessness and agitation, anxiety disorder, major depressive disorder, and cerebral infarction. On 03/02/25, Certified Nursing Assistant (CNA) C was assisting R1 in the bathroom and R1 became very agitated and was yelling at CNA C. CNA C reported to a nurse that R1 was upset when CNA C was providing cares. At 4:00 PM, Licensed Practical Nurse (LPN) D went to R1's room and R1 stated, The aide slammed me against the wall. On 03/03/25, Nursing Home Administrator (NHA) A completed an investigation. The Facility's Reported Incident (FRI) initial report was sent late to the State Agency (SA) on 03/13/25 at 4:05 PM and the final report was sent on 03/14/25 at 4:29 PM. The FRI report documented law enforcement was not contacted. The FRI did not document when NHA A was contacted to report the allegation of abuse. On 06/24/25 at 11:42 AM, Surveyor interviewed NHA A about when the allegation of abuse was reported to NHA A, SA, and law enforcement. NHA A stated NHA A was called right away and can't remember the time. Surveyor asked if CNA C was suspended during the investigation. NHA A stated when NHA A received the call from the facility, NHA A informed the staff CNA C should not be working with resident (R1) and needed to go home. Surveyor asked when CNA C clocked out at 8:00 PM, if this was the time NHA A was called about the incident. NHA A responded, yes. Surveyor asked if the incident occurred at 3:45 PM, if this was immediate reporting to NHA A. NHA A stated this was not timely reporting. Surveyor asked why the initial FRI was sent to the SA on 03/13/25 at 4:05 PM. NHA A stated NHA A thought it was sent in immediately. NHA A did not know why the report was not sent in timely. Surveyor asked when the allegation should be reported to NHA A and SA. NHA A stated within 2 hours. Surveyor asked if the police were called immediately. NHA A stated the police were not called because didn't feel it was necessary and could not prove abuse occurred.

Based on observation and staff interview, the facility did not ensure food was stored and served under sanitary conditions. This practice had the potential to affect 32 residents. Foods opened without a date. Dry storage items found on the floor. Temperature documentation missing for temping foods. Temperature/Chlorine documentation for dishwasher missing. Findings: The FDA Food Code 2022 documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (Celsius) (41 F) (Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. The FDA Food Code 2022 documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition: (A) A food specified in 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17 (A). The FDA Food Code 2022 documents at 3-305.11 Food Storage. (A) Food shall be protected from contamination by storing the food: (1) In a clean, dry location. (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. The FDA Food Code 2022 documents at 3-501.16 Time/temperature Control for Safety Food, hot and cold holding. (A) .time/temperature control for safety food shall be maintained: (1) At 57 C (135 F) or above .or (2) At 5 C (41 F) or less. Foods opened no date/Dry storage on floor: On 05/28/24 at 9:20 AM, Surveyor conducted an initial tour of the kitchen with [NAME] J. Surveyor found an open package of frozen chicken and fish fillets without a date opened. [NAME] J replied, I will throw that away. We are just so short staffed. Surveyor observed a gallon of milk opened and not dated in the refrigerator. [NAME] J replied, I will get rid of that. Surveyor observed a 50lb box of Idaho potatoes sitting on the floor in the dry storage as well as 'Quick Oats' in a five-gallon pail with about an inch of oats at the bottom of the pail. Temperature/Documentation missing: On 05/28/24 at 9:32 AM, Surveyor reviewed temperature logs for temping foods and noted missing temperatures on the PM shift on May 3, 7, 11, 23, 24, 25, 26. Surveyor asked [NAME] J for March and April. March log was missing supper food temperatures on March 17, 18, 30 and 31. April log was missing supper food temperature on the 31st. Surveyor noted missing temperature/chlorine Parts Per Million (PPM) in May on 1, 3, 6, 8, 12, 13, 15, 17, 19 and 20. Surveyor asked for March and April documentation. [NAME] J was unable to find where March documentation is kept. April log missing PM rinse and PPM for 3, 9, 20, 11, 17, 19, 22, 24, and 27.

Based on observation, record review and interview, the facility did not implement a restorative program in attempt to improve or maintain residents' functional abilities for 5 of 7 residents (R21, R15, R12, R29 and R7) reviewed for limited Range of Motion (ROM). Findings: R21 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) of 08 which indicated moderate cognitive impairment. Diagnoses of sepsis right knee prosthetic, diabetes, and disruption of wound. R21 had no changes in mobility status from Minimum Data Set (MDS) dated [DATE] to 03/24/24. On 05/29/24 at 2:00 PM, Surveyor interviewed Nursing Home Administrator (NHA) A asking for any information the facility would have on a restorative program for R21's limited ROM. NHA A replied, I'm sorry but we do not have a restorative program here. On 05/30/24 11:04 AM, Surveyor interviewed Certified Nursing Assistant (CNA) K, What type of position/mobility areas does this resident require your help with? CNA K replied, Needs repositioned every 2 hours at least. Surveyor asked CNA K, Has this resident's mobility improved or worsened? CNA K replied, Stayed about the same. Example 2: R15 was admitted on [DATE] with a BIMS unable to complete. Diagnoses of cerebral infarction (is a life-threatening medical condition that happens when there's a lack of blood flow to a part of your brain), and muscle weakness. Review of MDS quarterly assessment, dated 02/07/24, documented R15 having functional limitation of range of motion to both lower extremities and does not receive therapy services or restorative nursing services. On 05/29/24 at 2:00 PM, Surveyor asked NHA A for any information the facility would have on a restorative program for R15's limited ROM. NHA A replied, I'm sorry but we do not have a restorative program here. On 05/30/24 10:29 AM, Surveyor asked CNA K, What kind of things do you help this resident with regarding mobility/positioning? CNA K replied, Washing, catheter care, and easy stand. Example 3: R12 was admitted on [DATE] with a BIMS of 10 indicating moderate cognitive impairment. Diagnoses of above the knee amputation of the right leg in 2019, cerebral infarct with no residual deficits, dementia, and Huntington's (the disease affects a person's movements, thinking ability and mental health). Review of MDS quarterly assessment, dated 04/13/24, documented R12 having functional limitation of range of motion to one side of the lower extremities and does not receive therapy services or restorative nursing services. On 05/29/24 at 2:00 PM, Surveyor asked NHA A for any information the facility would have on a restorative program for R12's limited ROM. NHA A replied, I'm sorry but we do not have a restorative program here. On 05/30/24 9:57 AM, Surveyor interviewed Licensed Practical Nurse (LPN) I regarding ADL decline. LPN I replied, We assess for changes for ADL and look for ways to help either maintain or improve a resident's ADL involvement if they are able to. On 05/30/24 at 10:23 AM, Surveyor interviewed CNA K about R12's limited ROM. Surveyor asked CNA K, What kind of things do you help this resident with regarding mobility/positioning? CNA K replied, Shower, changing resident, resident eats in bed which requires a lot of bed changes. 47807 Example 4 Resident (R) 7 was admitted to the facility on [DATE] and has a diagnosis that includes Alzheimer's/dementia. R7 could not complete a BIMS due to not being able to understand or be understood. Review of MDS quarterly assessment, dated 04/04/24, documented R7 having functional limitations of range of motion to one side of the upper and lower extremities and is dependent on staff to provide activities of daily living. R7 does not receive therapy services or restorative nursing services. On 05/29/24 at 9:15 AM, Surveyor observed R7 in the activity room listening to a book being read. No restorative activities were being completed by R7 at this time. On 05/29/24 at 10:20 AM, Surveyor observed R7 being moved to a room for repositioning and care. R7 was wheeled from the activity room to their own room. On 05/29/24 at 12:27 PM, Surveyor interviewed contracted occupational therapy staff regarding restorative programs. Surveyor confirmed that R7 was not on any restorative plan that occupational therapy knew of. On 05/29/24 at 3:56 PM, Surveyor interviewed NHA A regarding R7's restorative plan. NHA A confirmed that R7 did not have any kind of restorative plan, and they were planning on looking into starting a restorative plan in the very near future. 16692 Example 5: R29 was admitted to the facility on [DATE] and has diagnoses that include morbid obesity, failure to thrive, post thrombotic syndrome with ulcer of bilateral lower extremity, pain in both knees, and abdominal hernia. R29's admission MDS, dated [DATE], indicated there are limits in range of motion in both upper extremities and lower extremities. These impairments affect both sides of R29's body. On 05/28-29/24, Surveyor reviewed R29's medical record and could not find information related to any exercises or programs that were being used to assist R29 in maintaining or increasing their range of motion. On 05/29/24 at 11:52 AM, Surveyor requested further information in relation to R29's range of motion program. On 05/29/24 at 4:58 PM, Surveyor interviewed NHA A asking about R29's restorative program. NHA A stated they did not find a range of motion program for R29. Currently there is not a restorative program.

Based on record review and interview, the facility did not conduct a comprehensive and accurate assessment for 1 of 13 residents (R) reviewed for Minimum Data Set (MDS) assessments. (R5) Findings: R5 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) of 08 (cognition is moderately impaired). Diagnoses of Alzheimer's, dementia, and congestive heart failure (a long-term condition in which the heart can't pump blood well enough to meet your body's needs). R5's MDS dated [DATE] under section I indicated that R5 had an active diagnosis in the major disease category of infection to a wound. On 05/28/24 at 11:00 AM, Surveyor asked Nursing Home Administrator (NHA) A about this resident's wound infection indicated on the MDS under the major disease category. NHA A replied, I will get that information for you. On 05/28/24 at 2:00 PM, Surveyor interviewed NHA A about the MDS. NHA A replied, The MDS was coded incorrectly on 05/01/24 the quarterly 180 day assessment, 01/30/24 for the quarterly 90 day assessment and 10/30/23 the annual MDSs as there is no major wound infection. On 05/30/24 at 9:43 AM, Licensed Practical Nurse (LPN) I provided Surveyor with the corrections submitted for the I section on the MDS for 01/20/23, 04/22/23, 07/23/23, 10/30/23, 01/30/24 and 05/01/24.

Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 3 of 8 staff reviewed. Findings include: Facility policy entitled, Resident Safety and Abuse Policy, last reviewed 3/24, states in part: Employee Screening: .All employees shall have a criminal background check. 1. Initial and any required future background checks will be conducted in accordance with applicable state and federal laws. Checks may include criminal history, state caregiver registry, OIG [Office of Inspector General], and exclusion lists. The type, frequency, and timing of checks will be in accordance with applicable state and federal law . On 05/28/24 at 3:48 PM, Surveyor reviewed caregiver background checks for 8 randomly selected staff members and found the following information: Registered Nurse (RN) G was hired on 02/29/24. Surveyor received a Background Information Disclosure (BID) dated 02/29/24 but did not receive a Department of Justice (DOJ) response or Integrated Background Information System (IBIS) letter for RN G's caregiver background check at the time of hire. On 05/28/24 at 4:30 PM, Surveyor interviewed Business Office Manager (BOM) C and asked why there was no DOJ response or IBIS letter for RN G's caregiver background check. BOM C stated RN G was a new hire, and they don't run the caregiver background check until 45 days after hire if there was nothing disclosed on the BID. On 05/28/24 at 4:45 PM, Surveyor interviewed Corporate Nursing Home Administrator (CNHA) D and asked why there was no caregiver background check for RN G. CNHA D stated they have 60 days by law to run the caregiver background check for new hires, and their company did not usually run it until 45 days after hire. Surveyor asked if it had been greater than 60 days since RN G was hired. CNHA D confirmed it was greater than 60 days since RN G's date of hire and the background check was overdue. Surveyor clarified RN G's background check was 29 days overdue. Surveyor did not find evidence of supervision of staff prior to background checks being completed. Surveyor reviewed Housekeeper (HK) E's records provided and found a BID dated 04/24/20, and the DOJ response and IBIS letter were both dated 04/27/24. This was greater than 4 years ago. Surveyor reviewed Certified Nursing Assistant (CNA) F's records provided and found a BID, DOJ response and IBIS letter all dated 02/18/20. This was greater than 4 years ago. On 05/28/24 at 4:30 PM, Surveyor interviewed BOM C who confirmed both HK E and CNA F's caregiver background checks appeared to be overdue. BOM C would look to see if they were done more recently. On 05/29/24 at 10:39 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who confirmed they did identify a problem with late caregiver background checks on the three employees listed above. NHA A stated they have already started a Performance Improvement Process to correct this problem and better identify when all staff are due for the background check to be run.

Based on observation, interview and record review, the facility did not provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility did not ensure proper hand hygiene practices were followed during resident care and wound care observations. This occurred for 2 of 7 residents (R) 31 and R15. Findings include: Example 1: The facility policy, entitled, Infection Prevention and Control Program, revised in February of 2024, stated, The World Health Organization (WHO) guidelines for hand hygiene are followed for all employees state in part: Hand hygiene and medical glove use . the use of gloves does not replace the need for cleaning your hands. Hand hygiene must be performed when appropriate regardless of indications of glove use. Remove gloves to perform hand hygiene, when indication occurs while wearing gloves. Discard gloves after each task and clean your hands - gloves may carry germs .Examination gloves indicated in clinical situations .Indirect patient exposure: emptying emesis basin; handling/cleaning instrument; handling waste; cleaning up spills of bodily fluids .2 Before clean. Clean your hands immediately before accessing a critical site with infectious risk for the patient .b) Before dressing a wound with or without instrument. On 05/29/24 at 7:26 AM, Surveyor observed cares for R31 performed by Certified Nursing Assistant (CNA) H. During cares, CNA H performed peri care for R31 who was incontinent of bowel. After cleaning the resident's bowel movement (BM), CNA H used gloved hands to throw out the dirty brief, cloths, incontinence pads, and dirty linens in a plastic bag. CNA H then removed their gloves and put them in the trash bag. CNA H did not perform hand hygiene. CNA H proceeded to grab a clean brief and clean pad, put them on the resident, and completed cares. CNA H did not don new gloves and used bare hands for the rest of cares for R31. On 05/29/24 at 7:47 AM, Surveyor interviewed CNA H asking why they did not perform hand hygiene or don new gloves after touching dirty items. CNA H said they did not have more gloves for them to use in the room, and once they were started, they were too nervous and just continued with care. Surveyor then asked if they would normally have stopped and got the materials needed to perform cares. CNA H said yes, they normally would have stocked them before cares were started and today, they were just nervous. On 05/30/24 at 1:19 PM, Surveyor interviewed Director of Nursing (DON) B regarding hand hygiene during cares. DON B said they would expect staff to have stocked the needed items before performing cares and the use of gloves and hand hygiene throughout the entire cares process. DON B would have expected the CNA to use hand hygiene and then donned gloves after the handling of dirty items. 46694 R15 was admitted on [DATE] with diagnoses of diabetes, osteomyelitis (bone infection that can result from fungi or bacteria), severe sepsis with shock (a serious medical condition that can occur when an infection in your body causes extremely low blood pressure and organ failure due to sepsis). On 05/30/24 at 7:14 AM, Surveyor observed DON B perform a dressing change on R15. DON B put on proper personal protective equipment (PPE) following hand hygiene with Alcohol Based Hand Rub (ABHR). DON B removed wound dressing then changed gloves without performing hand hygiene. DON B sprayed the wound with wound cleanser. DON B changed gloves but did not perform hand hygiene in between. Surveyor interviewed DON B and asked, What is the facility policy regarding hand hygiene with glove changes? DON B replied, You are making me nervous; I am supposed to perform hand hygiene. DON B then removed gloves and performed hand hygiene.

Based on observation, interview and record review, the facility did not have behavior monitoring for targeted behaviors, and non-pharmacological interventions for behaviors prior to the use of psychotropic medications. The facility did not have an appropriate indication for use for the psychotropic medication. This occurred for 2 of 3 residents (R) reviewed for unnecessary medications. (R1, R2) -R1 and R2 received anti-anxiety medications that did not include adequate indication for use of this medication. -The facility does not have a system for monitoring and documenting behaviors, and effectiveness of medications, or non-pharmacological interventions implemented prior to the use of psychotropic medication. Findings: R1 was admitted to the facility on [DATE]. Diagnoses included dementia, panic disorder, depression, and insomnia. R1 was not present in the facility during the survey. R1's physician orders included the following: haloperidol 0.5 mg twice daily for agitation/delirium. Lorazepam 1 mg three times daily for anxiety, restlessness, or nausea at 6:00 AM, 4:00 PM and at bedtime. Lorazepam 1 mg every two hours as needed for anxiety, restlessness, or nausea. Morphine 5 mg every two hours as needed for pain or shortness of breath. Pharmacy review on 07/25/23 for as needed (PRN) lorazepam requesting clinical rationale for use and duration of use. Physician response to continue for six months related to aggressive behaviors. Aggressive behaviors is not a medical symptom for continued use. Pharmacy review on 10/24/23 recommended a gradual dose reduction (GDR) of haloperidol. Physician response indicated R1 has had significant anxiety that has put R1 at risk of care delivery and risk/benefits have been discussed. Continue current medication for the next six months. Diagnosis: End stage Alzheimer's disease. Alzheimer's disease is not an indication of use for psychotropic medication. R1's minimum data set (MDS) assessment completed on 10/20/23 confirmed Brief Interview for Mental Status (BIMS) was not completed due to severe impairment. PHQ 9 score was 4 indicating mild depression. Behaviors exhibited: hallucinations and delusions. No physical or verbal behaviors, no rejection of care, and no wandering. Surveyor was unable to locate any documented hallucinations or delusions. R1 does not have a care plan indicating hallucinations or delusions. R1's care plan included: -Alteration in thought processes, forgetfulness, and confusion related to loss of memory, cognitive impairment, dementia, and sensorineural hearing loss. Manifested by difficulty with decision making, dementia, fluctuating awareness, restlessness, confusion, and disorientation. Nurses to assess change in level of consciousness, reorient/re-direct, observe for signs and symptoms of disease administer medications as ordered, observe for side effects and effectiveness, offer verbal cues, offer non-verbal cues. -Disruptive verbally related to dementia. Defiant behaviors and arguing with staff and other residents. Manifested by verbal outbursts, verbal intimidation, yelling at staff. Arguing about having a roommate and disagreeing with skilled nursing facility expectations. Becoming angry with implemented all interventions and calling staff liars when reminded of frequent falls. Nurses to administer medications as ordered. Provide calm environment. 1:1 conversation. Offer activity. Document behaviors exhibited. Surveyor unable to locate non-pharmacological interventions attempted prior to administration of medication. Surveyor unable to locate behavior monitoring documentation. R1 sustained seven falls in the previous 90 days. Review of medication administration record: -07/03/23 at 1:18 AM, Morphine for agitation, restless, calling out. No straight answer if he is in pain he just continues to ask for [name]. -07/16/23 at 1:08 PM, lorazepam for trying to stand. -07/30/23 at 10:57 AM, Morphine for standing up, calling out. at 11:40 AM, lorazepam for restless, trying to stand, hollering. -08/22/23 at 1:29 PM, lorazepam for yelling, trying to self-transfer. -09/04/23 at 2:19 PM, lorazepam for multiple attempts to get up from his Broda chair. -09/08/23 at 12:19 AM, lorazepam for yelling out attempting to get out of bed. -09/09/23 at 7:33 AM, lorazepam for yelling out, trying to crawl out of his chair. -09/21/23 at 12:50 AM, lorazepam for behavior yelling out. -09/25/23 at 2:40 AM, lorazepam for yelling, setting his motion alarm off. -09/26/23 at 2:36 AM, lorazepam for frequently attempting to get out bed. -09/30/23 at 1:56 AM, Morphine for yelling out. at 11:23 AM, lorazepam for agitated yelling. -10/01/23 at 10:47 AM, lorazepam for restlessness, trying to get up from his Broda chair. -10/14/23 at 4:21 PM, lorazepam for anxiety, still trying to get out of his chair. -10/19/23 at 1:10 PM, lorazepam for restlessness, result pain reduced. -11/19/23 at 2:12 PM, lorazepam for had a fall, restless, getting out from his chair. at 2:13 PM, Morphine restless, getting up from chair, had a fall earlier. -12/25/23 at 1:40 PM, lorazepam for restless in chair, trying to get up, related to falls. -01/09/24 at 6:45 PM, lorazepam for comfort. -10/17/23-01/17/24, lorazepam was administered 32 times with no reason documented. -10/17/23-12/26/23, morphine was administered 8 times with no reason documented. Over a 6 month period, R1 was given antianxiety medication for yelling out. R1 was given antianxiety medication 13 times for attempting to get up out of the chair or bed. The medication was not used for a medical reason, but to prevent R1 from yelling and moving about. Example 2 R2 was admitted to the facility on [DATE]. Diagnoses included vascular parkinsonism, generalized anxiety, and depression. R2's physician orders included haloperidol 1 mg twice daily for behavioral problems and anxiety, Seroquel 50 mg twice daily for agitation, lorazepam 0.5 mg every two hours as needed for anxiety, restlessness, or nausea. R2's MDS completed on 11/28/23 confirmed a score of 10/15 during BIMS, indicating moderate cognitive impairment. R2 scored 1 during PHQ 9, indicating minimal depression. Behaviors: Hallucinations. Physical and verbal aggression 1-3 days. No behaviors of rejection of care or wandering. R2's care plan included: -Wandering related to confusion, manifested by resident leaving room without assistance. Nurses to document any elopement attempts. -Adverse medication side effects related to anti-anxiety and antipsychotic use. Goal no adverse effects, minimize side effects. Resident will receive the lowest possible dose to control symptoms. Surveyor was unable to locate documentation of hallucinations. R2 does not have a care plan indicating hallucinations. Surveyor was unable to locate non-pharmacological interventions attempted prior to administration of medication. Surveyor was unable to locate behavior monitoring documentation. R2 sustained seven falls in the previous 90 days. R2's administration record: -08/23/23 at 6:52 AM, lorazepam, progress note reads, R2 1:1 from 2:00 PM until 7:15 PM. R2 went to sleep after taking HS meds and PRN lorazepam. -08/25/23 at 7:05 PM, lorazepam, for setting off alarm. -08/26/23 at 8:57 AM, lorazepam for self-transferring. at 10:59 AM, lorazepam for self-transferring. -08/28/23 at 3:54 PM, lorazepam for setting alarms off many times. 4:26 PM, lorazepam, Seroquel did not help. Anxious, getting up and down, wants to walk, lay down, very restless and requiring 1:1. -08/29/23 at 11:21 PM, lorazepam, restless. Effective, sleeping. -08/30/23 at 10:11 AM, lorazepam for up and down from chair, wants to go to the bookstore across the street. Is at front desk with staff and has been 1:1 a good part of the morning. at 3:22 PM, lorazepam for pain. -08/31/23 at 2:22 PM, lorazepam for wanting to get up and setting off her alarms and picking at things on the floor that are not there. -09/01/23 at 1:43 PM, lorazepam for up and down from chair, setting off alarms. Has been 1:1 most of the morning. at 7:30 PM, progress note reads: R2 requires constant 1:1. She tries to get up from her chair multiple times, literally minimum of every minute. Chair alarm sounds each time. It took 10 minutes to give her medications. It took two staff to lay her down. It took a good 30 minutes to care for her. Total time with resident, 2 staff for HS cares, 10 minutes to give her meds, 30 minutes for cares=40 minutes. This is in addition to the constant 1:1 and staff keeping an eye on her at sight length. (Surveyor notes staff are administering the antianxiety medication due to the amount of time the resident is taking for cares) -09/02/23 at 2:28 PM, Morphine for no complaints of pain but is still agitated. at 2:49 PM, lorazepam for constantly alarming her alarm, standing up and down, does not comprehend instructions. at 3:16 PM, progress note reads, has been 1:1 ALL DAY, setting off alarms many many times and not sure on what she wanted just wants to go. Has been given magazines, drawing paper, pens, cards, food/drink, phone, taken to the bathroom, refuses to take that damn little white pill. at 7:21 PM, lorazepam for up and down in her chair. -09/03/23 at 2:04 PM, lorazepam for 1:1 for the day and setting off alarms. -09/05/23 at 8:00 PM, lorazepam, result effective is sleeping. -09/08/23 at 10:57 AM, lorazepam for up and down from chair and setting off alarms and not wanting anything. at 8:37 PM, lorazepam for crawling out of chair, pulling on things, standing. -09/09/23 at 1:10 PM, lorazepam for standing, setting off alarm. -09/10/23 at 4:49 PM, lorazepam for self-transfer, upset, wont sit down. -09/16/23 at 3:10 PM, lorazepam for up and down, setting off alarms, not wanting to sit still or be with others. at 3:37 PM, lorazepam getting up and down in her chair, setting off alarms. at 11:44 PM, lorazepam for frequent setting of both bed and chair alarm. -09/20/23, progress note reads, was started on Haldol today. Resident requiring 1:1 entire shift. Continues attempting to get out of wheelchair. -09/23/23 at 6:05 PM, lorazepam for setting off alarm. at 9:22 PM, lorazepam for transferring. -09/25/23 at 2:47 AM, haloperidol, attempting to get up on her own. -10/31/23 at 5:00 PM, lorazepam for standing, arguing. -11/18/23 at 7:27 PM, lorazepam for getting up from chair. -12/28/23 at 7:37 PM, lorazepam for setting off alarm. -08/22/23-01/08/24, lorazepam administered 18 times with no reason documented. On 01/24/24, Surveyor requested behavior monitoring. Surveyor received the following: -11/18/23, R2 was kicking and hitting x5. -12/11/23, R2 was kicking, hitting, biting, and pinching. -08/25/23, R2 was hitting/punching staff. -08/28/23, R2 was pushing/grabbing staff. -09/04/23, R2 was aggressive with staff. -09/13/23, R2 required 1:1 staff assist, getting up from wheelchair. -10/21/23, R2 was tearful. -12/22/23 and 12/23/23, R2 scratched staff. -01/04/24, R2 was pushing and grabbing. Over the past 5 months, R2 has been given an antianxiety medication 25 times for attempting to stand or setting off the alarm on her chair. On 01/24/24 at 8:10 AM, Surveyor observed R2 in Broda chair at nurse's station. R2 was leaning forward in her chair with both hands on the armrests of the chair, attempting to push herself up and out of her chair. Surveyor did not observe staff intervene; however, R2 was unable to exit her chair. On 01/24/24 at 11:11 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C. CNA C stated R2 has a chair alarm because she is up and down. Surveyor observed R2's chair alarm was not turned on. On 01/24/24 at 12:40 PM, Surveyor interviewed Licensed Practical Nurse (LPN) D. LPN D reported PRN lorazepam and scheduled Haldol are given because R2 strikes out. LPN D reported R2 does not hallucinate but is not in touch with reality and makes statements such as, I can't pull it together. LPN D reported R2 always wants to go, for example wants to go upstairs, across the street, or go home. LPN D stated, R2 just wants to be up. On 01/24/24 at 2:42PM, Surveyor interviewed LPN E. LPN E reported behaviors for administering lorazepam include physical aggression, repetitive movements, wandering, elopement, verbal abuse, resisting cares, and attempts to self-transfer. LPN E reported non-pharmacological interventions include ambulating with staff, set-up for cares, television, and 1:1 at the nurse's station. LPN E stated behavior monitoring is documented in electronic record, and stated R2's behaviors are, she is up and down, and she literally does not listen. On 01/24/24 at 2:50 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated LPN D completes behavior monitoring and referred Surveyor back to LPN D.

Based on observation, interview and record review, the facility did not ensure that 1 of 3 residents (R2) reviewed for falls had adequate supervision and assistance to prevent accidents. R2's care plan indicated the use of an alarm while in wheelchair. R2's alarm was not in the 'ON' position. Findings: R2 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease. R2's care plan includes the following: grab bars, pressure alarm in wheelchair and bed. R2's physician orders include the following: haloperidol 1 mg twice daily for behavioral problems and anxiety. Seroquel 50 mg twice daily for agitation. Lorazepam 0.5 mg as needed for anxiety, restlessness, or nausea. Supportive device: motion sensor at all times when in bed for safety due to falls. R2's falls: -10/13/23, fall in room, no injury. Intervention: Ensure alarm is on. -11/07/23, fall from wheelchair, no injury. Pressure alarm not functioning due to not being plugged in. Intervention: check alarm function when in wheelchair. -12/30/23, fall during attempt to ambulate, no injury. Alarm was not turned in the 'ON' position. Intervention: demonstrated to all CNAs how to turn new alarm on. On 01/24/24 at 8:26 AM, Surveyor observed R2 eating breakfast in the dining room. Surveyor observed R2's chair alarm to be in the off position. On 01/24/24 at 9:07 AM, Surveyor observed Certified Nursing Assistant (CNA) C transfer R2 from her wheelchair to her bed. CNA C attempted to turn the chair alarm off prior to transfer. CNA C stated the alarm was in the off position. CNA C stated R2's alarm should always be on due to R2 trying to get out of her chair, but unfortunately it was not on. On 01/24/24 at 2:41 PM, Surveyor interviewed Licensed Practical Nurse (LPN) E. LPN E reported only R2 has a chair alarm that can be turned on/off, as this is a new alarm and recently ordered. All other alarms used by facility are always on, as there is not an on/off switch. CNAs have been educated on ensuring R2's alarm is turned on.

Based on record review and interview, the facility did not consult with the resident's physician, consistent with his or her authority, and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 sampled residents (R2). The facility did not notify the physician or Power of Attorney (POA) promptly of R2's fall on 10/03/23 or consult with physician timely of increase in pain and change in ambulation status post fall. R2 was sent to the emergency room 4 days after the fall and was diagnosed with a fractured right hip. The delay in consulting with a physician prevented timely diagnosis of the fracture and caused ongoing pain with movement. This is evidenced by: Facility policy titled Incidents and Accidents dated 12/2013, revised 08/2021 states: Purpose: All incidents and accidents occurring on the facility premises must be investigated and reported to the Administrator. Medical Attention: The licensed Nurse will: iii. Notify the victim's personal or attending physician. iv. Notify the resident's family/responsible party. v. If necessary, transfer the injured person to the hospital. Facility policy titled Fall Assessment and Prevention Protocol dated 04/2020, revised 08/2021 states: After a fall or intercepted fall: 2. Notify attending or on-call physician according to the physician notification parameters policy and the change in resident's condition/status. 3. Notify the POA or other legal representative. Facility policy titled Nurse Charting Guidelines dated 2012, revised 07/2019 states: Some common acute conditions and a suggested timeframe of documentation include: 4. Nurse charting general documentation guidelines: e. Falls: Document after every single fall. The nurse should notify the attending physician, complete incident report paperwork, and make the family and/or responsible party aware. The physician or other provider on-call may order x-rays, CT (computerized tomography) scans or pain medications, so be sure to include any new orders in your nurses note. R2 was admitted to the facility on [DATE] with diagnoses including but not limited to violent behavior (combative), lower extremity edema, vascular dementia-unspecified severity with behavioral disturbance, and anxiety. R2's Minimum Data Assessment (MDS) dated [DATE] indicated R2: -required limited assist with transfers, walking, and eating, was dependent with bed mobility and dressing, and extensive assist with toilet use and personal hygiene. -had pain daily using nonverbal sounds, vocal complaints of pain, and facial expressions. -rarely /never understood -receiving antipsychotics -non-steroidal anti-inflammatory drug for pain control Review of the care plan. R2 had a comprehensive care plan. Main issues included: 10/12/22 Problem: Chronic pain related to psychological agents manifested by crying or moaning. Goal: Express feeling of comfort or of pain relief Interventions: Nurses to monitor pain characteristics: Administer pain meds, notify physician as needed. Notice signs/symptoms of increased pain due to poor communication. 09/24/19 Problem: Potential for trauma-falls related to history of falls, confusion, decline in cognitive status, unsteady gait, deconditioning, dementia with behavioral disturbance, use of psychotropic medications, and refusal to use assistive devices. Goals: No injury. Fewer than 5 falls per quarter. Interventions: Observe, record, and report all unsafe conditions and situations, therapy screen and evaluations as needed, encourage to ask for assistance, anticipate fall times, and monitor closely. Review of incident report dated 10/04/23 for R2's incident which occurred on 10/03/23 at 5:27 p.m., Licensed Practical Nurse (LPN) C documented R2 was in the dining room having dinner and stood up to walk back to a chair in the entry way of the facility. R2 was carrying a bowl of soup and slipped and fell into a sitting position on the floor. LPN C assessed R2. Vital signs attempted but R2 was upset and refused. LPN C obtained a temperature. LPN C documented R2's pupils were equal, round and reacted to light. Bilateral hand grasp firm. No apparent injury. No medications given within a couple hours prior to the fall. R2 had no complaints of pain. Steps to prevent reoccurrence: Closer monitoring. Allowing to eat in regular spot in the entry way. Reduce anxiety of multiple other people at table during meals. Cause documented as R2 in a trial eating with other resident in the dining room instead of normal area in the entry way by the nurse's station. LPN C documented Nurse Practitioner (NP) notified on 10/04/23 at 1:30 p.m. and message left for R2's POA to call the facility. LPN C signed the incident report and dated it 10/04/23. Physician and POA notified day after incident, not on the day the incident occurred. Review of R2's medical record: On 10/03/23, R2's medical record has no RN assessments or notes about fall incident or follow-up notes about fall and status of R2 post fall or physician notification. On 10/04/23 at 9:55 a.m., nursing documented acetaminophen 325 mg tab (2 tabs/650mg) given for crying ouch with movement from chair to chair and when at table. On 10/04/23 at 1:36 p.m., LPN C documented R2's fall, which was not the date of the incident. (Incident 10/03/23) On 10/04/23 at 1:53 p.m., nursing documentation states post-fall review: R2 has contributing diagnoses of arthritis, incontinence, and joint pain, receives antipsychotics, vital signs of Blood Pressure (B/P) 164/80, Temperature (T) 98.2, Pulse (P) 84, Respirations (R) 22, and oxygen saturation 98%. Nursing documentation stated R2 was out to dining room for both meals, when standing and moving will say ouch and cry a little, but when asked what is wrong, will complain of being scared. Documentation stated no marks or bruising on body, swelling in lower legs (normal). There is noted pain when standing; the physician was not consulted. On 10/04/23 at 9:42 p.m., nursing documentation states: post fall resident no complaints of pain. A little weaker with transfers. B/P 143/76, P 82, T 97.9, R 18, O2 saturation 97%. On 10/05/23 at 10:59 a.m., nursing documents Acetaminophen 325mg tablet (2 tabs/650mg) given for pain. Resident [R2] will cry out ouch ouch ouch with movement. Nursing noted pain with movement; physician not consulted. On 10/05/23 at 3:08 p.m., nursing documents resident (R2) has been up to the dining room for both meals and complains of pain and says ouch ouch ouch when moved, not wanting to stand on the right leg. No redness, no bruises noted. Note states: Has been reported to RN (Registered Nurse) and RN would be talking to the NP. Did have Tylenol this a.m., does not complain when sitting in the chair. R2 is not wanting to bear weight on the right leg post fall with complaints of pain. Physician not consulted. On 10/06/23 at 1:48 p.m., nursing documents Acetaminophen 325mg tab (2 tabs/650mg) given for pain in am (cries out with any movement) and R2 sleeping at 10:15 a.m. R2 is now crying out with any movement. The physician is not consulted. On 10/06/23 at 6:69 p.m., nursing documents no complaints from recent fall. Unable to get B/P, pulse, or oxygen sats due R2 uncooperative. Temperature was 98.3. On 10/07/23 at 7:22 p.m., nursing documentation states R2 transferred at 6:00 p.m. to acute care hospital by ambulance for evaluation from fall 4 days ago, significant change in ambulation and ongoing pain. POA was notified and agreed to evaluation. On 10/07/23 at 9:30 p.m., nursing documents RN from hospital stated R2 has a fractured right hip from fall 4 days ago and is septic with a UTI (urinary tract infection) and is being transferred to another facility for surgery. On 11/20/23 at 1:10 p.m., Surveyor interviewed LPN C and asked about R2's fall on 10/03/23 and asked why the physician was not notified. LPN C stated R2 did not complain of pain and the shift got busy and LPN C did not realize until 10/04/23 that R2's physician and family were not notified of the fall. LPN C stated LPN C notified them on 10/04/23. On 11/20/23 at 2:10 p.m., Surveyor interviewed Director of Nursing (DON) B and asked about R2's pain and increase in pain. DON B stated R2 will yell out. DON B stated DON B did not think R2's pain was increased from normal, and no staff brought any increased pain concerns to DON B. DON B stated R2 would always call out and say ouch because of the lower extremity edema R2 has. On 11/20/23 at 4:05 p.m., Surveyor interviewed DON B and asked how R2's physician was notified on 10/5/23 of the increased pain since the nursing documentation stated RN would notify the NP. Surveyor checked the schedule for 10/05/23, and the RN on duty was DON B. DON B stated DON B was not notified of this. DON B stated some of the nurses on staff will automatically go to the MDS Coordinator, who is an LPN (LPN F). DON B went to check if LPN F had any documentation. DON B provided Surveyor with an email that LPN F sent to R2's NP. The email states on 10/05/23 at 2:54 p.m. NP was emailed stating R2 was having much pain on left side following the fall. (LPN documented in email to NP the wrong side of the body. Email should have stated right leg). Wondering about an x-ray. NP emailed response to LPN F at 4:11 p.m. and asked where the pain was located. LPN F did not respond to the email until 10/06/23 at 3:31 a.m., 12 hours later to reply about R2's change in condition with increased pain post fall. LPN F documented R2 was favoring the right leg. An email is not consultation with the NP, as there is no way to ensure the message is received and addressed timely. The medical record contains no further information as to when the physician was consulted to determine that R2 should be sent out to the emergency roiagnom on [DATE] at 6:00 p.m.

Based on record review and interview, the facility did not ensure that 1 out of 3 sampled residents (R) R2 received assessment and appropriate medical care with a change in medical condition consistent with professional standards of practice for a licensed practical nurse (LPN) and a registered nurse (RN). R2 was not assessed for increased pain or change in ambulation ability after a fall on 10/03/23 to secure timely treatment for R2. On 10/07/23, four days after the fall, R2 was sent to the emergency room and was diagnosed with a fractured right hip. R2 experienced increased pain, especially with movement during the four days the fracture went undiagnosed . This is evidenced by: Facility policy titled Incidents and Accidents dated 12/2013, revised 08/2021 states: Purpose: All incidents and accidents occurring on the facility premises must be investigated and reported to the Administrator. Medical Attention: The licensed Nurse will: i. Physically assess and make injured person is safe and comfortable. Director of Nursing or RN Designee will i. Complete a physical assessment of the injured person. ii. Review all documentation. [NAME]. Follow-up by observing resident and/or reviewing post-incident documentation each shift for the first three days and at 1 week to evaluate effectiveness of interventions. Facility policy titled Fall Assessment and Prevention Protocol dated 04/2020, revised 08/2021 states: After a fall or intercepted fall: 4. Document the fall in the nursing charting tab. 7. Observe all residents for at least 48 hours after an observed or suspected fall and document relevant post-fall clinical findings in the nursing charting tab. Facility policy titled Nurse Charting Guidelines dated 2012, revised 07/2019 states: Some common acute conditions and a suggested timeframe of documentation include: c. Post-incident follow-up x 72 hours (Neurological checks per policy). According to the Wisconsin Standards of Practice for Licensed Practical Nurses (N6): In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (b) Provide basic nursing care . (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. According to N6.03(1), an R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill.The nursing process consists of the steps of assessment, planning, intervention and evaluation. R2 was admitted to the facility on [DATE] with diagnoses including but not limited to violent behavior (combative), lower extremity edema, vascular dementia-unspecified severity with behavioral disturbance, anxiety, unspecified dementia with psychotic disturbance. R2's Minimum Data Assessment (MDS) dated [DATE]: -required limited assist with transfers, walking, and eating, was dependent with bed mobility and dressing, and extensive assist with toilet use and personal hygiene. -had pain daily using nonverbal sounds, vocal complaints of pain, and facial expressions. -rarely /never understood -receiving antipsychotics -non-steroidal anti-inflammatory drug for pain control Review of R2's comprehensive care plan. Main issues included: 10/12/22 Problem: Chronic pain related to psychological agents manifested by crying or moaning. Goal: Express feeling of comfort or of pain relief Interventions: Notice symptoms of increased pain due to poor communication. 09/24/19 Problem: Impaired physical mobility related to perceptual or cognitive impairment . Goals: Maintain strength and endurance, maintain functional mobility. Interventions: . Aides-Ambulation-independent, bed mobility 1 assist . Review of incident report dated 10/04/23 for R2's incident which occurred on 10/03/23 at 5:27 p.m., LPN C documented R2 was in the dining room having dinner and stood up to walk back to a chair in the entry way of the facility. R2 was carrying a bowl of soup and slipped and fell into a sitting position on the floor. LPN C assessed R2. Vital signs attempted but R2 upset and refused. LPN C obtained a temperature. LPN C documented R2's pupils were equal, round and reacted to light. Bilateral hand grasp firm. No apparent injury. No medications given within a couple hours prior to the fall. R2 had no complaints of pain. Steps to prevent reoccurrence: Closer monitoring. Allowing to eat in regular spot in the entry way. Reduce anxiety of multiple other people at table during meals. Cause documented as R2 in a trial eating with other resident in the dining room instead of normal area in the entry way by the nurse's station. LPN C documented Nurse Practitioner notified on 10/04/23 at 1:30 p.m. and message left for R2's POA (Power of Attorney) to call the facility. LPN C signed the incident report and dated it 10/04/23. Review of R2's medical record: On 10/03/23, R2's medical record has no assessments or notes about the fall incident or follow-up notes about R2's fall and status of R2. There is no RN assessment or verification of LPN data by RN in R2's medical record. On 10/04/23 at 9:55 a.m., nursing documented Acetaminophen 325 mg tab (2 tabs/650mg) given for crying ouch with movement from chair to chair and when at table. On 10/04/23 at 1:36 p.m., LPN C documented R2's fall, which was not the date of the incident. (Incident 10/03/23) On 10/04/23 at 1:53 p.m., nursing documentation states post-fall review: [R2] has contributing diagnoses of arthritis, incontinence, and joint pain, receives antipsychotics, vital signs of Blood Pressure (B/P) 164/80, Temperature (T) 98.2, Pulse (P) 84, Respirations (R) 22, and oxygen saturation 98%. Nursing documentation stated resident (R2) was out to dining room for both meals, when standing and moving will say ouch and cry a little, but when asked what is wrong, will complain of being scared. Documentation stated no marks or bruising on body, swelling in lower legs (normal). On 10/04/23 at 9:42 p.m., nursing documentation states: post fall resident no complaints of pain. A little weaker with transfers. B/P 143/76, P 82, T 97.9, R 18, O2 saturation 97%. Nursing note documented by LPN. Post fall assessment documentation noted only on 10/04/23 at 1:53 p.m. and 9:42 p.m. On 10/05/23 at 10:59 a.m., nursing documents Acetaminophen 325mg tablet (2 tabs/650mg) given for pain. R2 will cry out ouch ouch ouch with movement. Nursing note documented by LPN. No RN assessment of R2 when noted increased crying out in pain with movement. An email from LPN F to the NP on 10/05/23 at 2:54 p.m. states R2 was having much pain on left side following the fall. (LPN documented in email to NP the wrong side of the body. Email should have stated right leg). Wondering about an x-ray. On 10/05/23 at 3:08 p.m., nursing documents R2 has been up to the dining room for both meals and complains of pain and says ouch ouch ouch when moved, not wanting to stand on the right leg. No redness, no bruises noted. Note states: Has been reported to RN (Registered Nurse) and RN would be talking to the NP. Did have Tylenol this a.m., does not complain when sitting in the chair. Nursing note documented by LPN. There is no RN assessment of the right leg for indication of a hip fracture. There was no follow up with the provider on this date. Nurse reported the above findings to LPN F not to an RN. The RN on shift was DON B, who was not informed of the change of condition for R2. On 10/06/23 at 6:39 p.m., nursing documents no complaints from recent fall. Unable to get B/P, pulse, or oxygen sats due to resident R2 uncooperative. Temperature was 98.3. Nursing note documented by RN. There is no post fall assessment. On 10/06/23 at 1:48 p.m., nursing documents Acetaminophen 325mg tab (2 tabs/650mg) given for pain in am (cries out with any movement) and R2 sleeping at 10:15 a.m. Nursing note documented by LPN. No RN assessment with R2 crying out in pain. MayoClinic.org Signs and symptoms of a hip fracture include: Inability to get up from a fall or to walk. Severe pain in the hip or groin. Inability to put weight on the leg on the side of the injured hip. Bruising and swelling in and around the hip area. Shorter leg on the side of the injured hip. Outward turning of the leg on the side of the injured hip. R2's medical record did not contain assessment for one leg shorter than the other, or outward turning of the leg on the injured side in the 4 days following R2's fall. On 10/07/23 at 7:22 p.m., nursing documentation states R2 transferred at 6:00 p.m. to acute care hospital by ambulance for evaluation from fall 4 days ago, significant change in ambulation and ongoing pain. POA was notified and agreed to evaluation. Nursing note documented by RN. No RN assessment for reason for pain or significant change in ambulation or as to why R2 was sent out at this time. There is no documentation or assessment of R2's condition/status between 10/06/23 at 1:48 p.m. and 10/07/23 at 7:22 p.m. when R2 was sent out to the hospital for evaluation. This is a time period of over 29 hours with no assessment of condition when R2 had a recent fall with increased pain and a change in ability to bear weight on the right leg. On 10/07/23 at 9:30 p.m., nursing documents RN from hospital stated resident R2 has a fractured right hip from fall 4 days ago and is septic with a UTI (urinary tract infection) and is being transferred to another facility for surgery. Nursing note documented by RN. On 11/20/23 at 1:04 p.m., Surveyor interviewed RN D. RN D worked on 10/03/23-date of R2's fall incident. Surveyor asked about R2's fall on 10/03/23. RN D stated that it was a while ago. Surveyor asked if RN D assessed R2. RN D stated RN D didn't remember if R2 was assessed. Surveyor asked if R2 required an evaluation for dislocation/fracture. RN D stated RN D had no idea about an evaluation. RN D stated RN D did not work with R2. On 11/20/23 at 1:10 p.m., Surveyor interviewed LPN C and asked about R2's fall on 10/03/23. LPN C stated the facility was trying to integrate R2 in the dining room for meals for closer monitoring, but R2 was used to sitting in a chair in the entry way by the nurse's station. So, at mealtime, R2 stood up, lost balance, and sat on the floor. Surveyor asked what occurred after R2 fell . LPN C stated LPN C assessed resident by taking vital signs, did neuro checks, check range of motion (ROM), rotation of hips/legs and resident did not complain of any pain. LPN C stated the only thing R2 was upset about was spilling R2's soup. Surveyor asked if R2 complained at all at any time on 10/03/23 of any pain in hip or leg. LPN C stated R2 did not complain of any pain. Surveyor asked LPN C if an RN was contacted about what data collection should be obtained. LPN C could not explain why this was not done. On 11/20/23 at 2:10 p.m., Surveyor interviewed Director of Nursing (DON) B and asked about R2's change in ambulation ability and increase in pain after the fall on 10/3/23. DON B stated R2 will yell out. DON B stated DON B did not think R2's pain was increased from normal, and no staff brought any increased pain concerns to DON B. DON B stated R2 would always call out and say ouch because of the lower extremity edema R2 has. DON B acknowledged there had been no comprehensive assessment of R2 when R2 experienced increased pain and increased difficulty standing on the right leg. On 11/20/23 at 4:05 p.m., Surveyor asked DON B what the facility policy for pain assessment is. DON B stated a nurse should assess pain every time they come in contact with the resident. Surveyor asked if that was the facility policy and DON B could not answer the question. Surveyor asked what happens if the nurse on duty is an LPN. DON B stated the LPNs do the assessments. Surveyor asked if there were any RN assessments for R2's status post fall. DON B did not answer the question. DON B did not have any additional information as to why R2 had no assessment for over 29 hours when exhibiting a change of condition post fall prior to being sent to the hospital. R2's history and physical from hospital: Date of admission 10/08/23 at 12:45 a.m., documents R2 was found to have a subcapital right hip fracture. R2 was febrile at 101.7 degrees Fahrenheit, and urinalysis was suggestive of infection, R2 was given ceftriaxone. WBC normal, hemoglobin 9.3 low, creatinine 0.99 normal, red blood cell count 3.18 low. R2's hospital discharge summary report dated 10/11/23 documents R2 was transferred to another hospital and underwent repair of the right hip fracture.

Based on observation, interviews and record review, the facility did not ensure sanitary conditions while dishwashing. This has the potential to affect 37 of 37 residents in the facility. Kitchen staff moved from dirty to clean areas while washing dishes, without a change of gloves or handwashing done in between the tasks. This is evidenced by: On 5/23/23 at approximately 1:20PM, Surveyor observed Dietary Aide (DA) E walk into the dishwashing area wearing gloves with a dirty tray. DA E set the dirty tray down in the dirty side of the kitchen, opened the dishwasher door and moved the clean tray of dishes down the line, then went back and put the dirty tray in the dishwasher and closed the door. DA E did this all without changing gloves or washing hands. DA E was not wearing an apron, nor was there one available observed in the dishwashing area. On 5/23/23 at approximately 1:22PM, Surveyor interviewed DA E regarding what was observed. Surveyor asked DA E if they knew what was wrong with what they had just done. DA E responded that they did not. Surveyor explained to DA E the importance of keeping clean and dirty separate in a dishwashing area, and that DA E needed to wash hands and change gloves before moving from dirty to clean and back again. DA E stated that was something they did not know but that it made sense. DA E stated that they were never told of a need to wear an apron while dealing with dirty dishes. On 5/23/23 at approximately 1:25PM, Surveyor interviewed Dietary Manager (DM) F regarding what was observed in the dishwashing area. Surveyor asked DM F what was the proper procedure for dishwashing. DM F stated that DA E should have changed gloves, and not touched clean dishes with dirty gloves. On 5/23/23, Surveyor reviewed training of DA E. It was noted on the Dietary Aide Job Description form that a DA is to Maintain food service workspace in immaculately clean condition at all times in accord with facility procedures. Cleans workspaces, trays, and dishes according to department procedures. Loads and unloads dishwasher. Always follows infection control procedures. Utilizes personal protective equipment when indicated. This job description is signed by DA E. On 5/23/23, Surveyor reviewed the Dietary Aide Orientation check list for DA E. Under the subtitle of Administrative Functions, a box was checked as reviewed with DA E that stated DA E was trained in Maintenance of safe and clean kitchen/storage/office areas. This was signed by DA E and DM F on 5/5/23.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in a safe and sanitary manner. The facility staff had dusty fans blowing onto clean dishes in the dishwashing room and across the three-compartment sink. This did not ensure clean dishes to remain clean and sanitary. The facility staff did not ensure cups of milk for residents to drink were properly covered when stored in the refrigerator. This is evidenced by: On 04/03/22 at 9:29 a.m., Surveyor conducted initial tour of the kitchen with Dietary Cook (DC) L . Surveyor observed in the dishwashing area, two fans mounted to the wall and facing and blowing directly down onto clean dishes. Dietary Aide (DA) M turned off the fans and observed the fan blades containing dust and the fan screen with dust hanging down. Another larger fan was at the entrance of the dishwashing room blowing directly into the dishwashing room. This fan also had dust on the blades and dust on the screen. The direction the fans were blowing onto the clean dishes allowed for cross contamination onto the clean dishes. On 04/05/22 at 7:58 a.m., Surveyor observed DC L washing dishes at the three-compartment sink. A fan on a stand was at the dirty end of the sink blowing directly onto the clean dishes at the end of the sink. On 04/03/22 9:53 a.m., Surveyor observed in the kitchen, a refrigerator with two cups of white milk and two cups of chocolate milk and one cup of pink colored milk that was not covered. Surveyor interviewed DC L asking if the milk should be covered. DC L indicated the milk should be covered with a cloth until it is served to the residents. DC L placed a cloth to cover the milk. On 04/05/22 at 9:27 a.m., Surveyor interviewed Dietary Manager (DM) P asking about the use of the fans. DM P indicated the fans have been there and are cleaned regularly. Surveyor explained the fans being dusty and blowing directly onto the clean dishes allow for cross contamination. Surveyor reviewed with DM P of the observation of the milk being stored in the refrigerator uncovered. DM P indicated the milk should be covered.

Based on observation, interview and record review the facility did not ensure that residents were protected from sexual abuse when nonconsensual sexual activity occurred for 2 of 3 (R1, R2) residents reviewed. R1 and R2 did not have ability to consent to a sexual relationship. The facility did not stop the relationship and protect R1 and R2 from potential unwanted sexual advances or potential injury when it first occurred. Facility failure to protect vulnerable residents from sexual abuse created a finding of immediate jeopardy that began on 01/13/19. Surveyor notified the Nursing Home Administrator and Director of Nursing of the immediate jeopardy on 06/25/19 at 1:35 p.m. The immediate jeopardy was removed and corrected on 06/06/19. The deficient practice is being cited as past noncompliance. This is evidenced by: The facility policy, Resident Sexual Expression, dated 3/19, in part, .residents have the right to seek out and engage in consensual sexual expression with other residents .For persons who are cognitively impaired, the interdisciplinary team will determine the relative benefit or potential harm regarding sexual expression.involving the resident's legal representative and attending physician/medical provider. Protocol 2. b. In instances in which the sexual expression does not appear consensual, or is impacting negatively .the IDT makes an immediate intervention with an emphasis on diversion . R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] documents R1 is unable to answer the Brief Interview for Mental (BIMS) status questions. This means R1 cannot retain or recall information or answer questions regarding date, time or object identification. The interview for mental status shows R1 has severe cognitive impairment. R1's BIMS has been a 0 since his admission. R1's Healthcare Statement of Incapacity was signed by two physicians on 06/26/18, stating the resident is unable to receive and evaluate information effectively or communicate decisions to such an extent that the resident lacks the capacity to manage his healthcare decisions. R1 needs assistance for ambulation and assistance of one for dressing and hygiene. R1 has wandering behaviors daily and has disorganized thinking. The MDS shows R1 is married. R1's spouse is his Health Care Power of Attorney (HCPOA). R1 is not competent to make his own decisions, due to dementia. Surveyor reviewed R1's plan of care. The care plan for R1, dated 12/04/18, stated in part: Sexual intimacy, allow appropriate expression of sexuality and intimacy with another consenting resident (R2) Allow appropriate expression of sexuality and intimacy with another consenting resident (R2). Allow for privacy in resident's room for alone time. R2 was admitted [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], shows R2 has a BIMS of 3, meaning R2 has severe cognitive impairment. R2 cannot recall events, dates or identify objects. The quarterly MDS, dated [DATE], shows R2 has a BIMS score of 5, meaning R2 has severe cognitive impairments. R2's Healthcare Statement of Incapacity was signed by two physicians on 08/25/17. The MDS documents R2 is independent with bed mobility, ambulation, dressing and hygiene. The MDS shows R2 has wandering behaviors. R2 is not able to make her own decisions due to dementia and has an activated HCPOA. The care plan for R2 on 05/02/19 prior to the self-report incident, dated 12/04/18, stated in part, Allow appropriate expressions of sexuality and intimacy with relationship with another consenting resident (R1). Allow for privacy in resident's room for uninterrupted time alone together. Surveyor reviewed social services notes that include in part: 08/23/18 .Writer phoned wife (POA) to inform her of resident's friendship with (R2) and how we have seen it evolve. Activities went to invite residents to activities and found resident in (R2's) room .they seemed to have been kissing and possibly having relations .writer explained residents have a right to have relations as long as both residents are consenting . 11/27/18 .phone call from resident's daughter .stated the relationship resident had with another female resident at the facility was difficult for resident's spouse . 12/04/18 SW H contacted .POA-HC discussed resident changing rooms and moving to the east hallway. .resident would have his own room which may be more conducive to her/family's visits . 01/08/19 SW was informed resident's wife had visited over the weekend and was upset about the interaction/relationship between resident and another female resident .discussed resident's disease progression and (POA name) admitted she knew resident found comfort in the relationship .SW stated .they would often redirect the female resident throughout the day when they observed her going down to resident's room . 01/17/19 .discussed the difficulty in accepting resident's relationship with a female resident at facility .discussed resident's disease progression and his inability to understand he was 'married' and what this meant in regards to him having another relationship . Surveyor reviewed the nurses' notes from (MONTH) (YEAR) to present for R1 and R2. R1's notes in part: 01/13/19 Resident found sitting on his bed naked with another resident who was naked from the waist down. Residents were separated and individually brought out to the dinner table. This writer had seen both residents about a half hour before this incident not together. 01/24/19 Late entry for 01/23/19 at 10:30 a.m., (R1's name) was in his room. (R2) was on his bed with her clothing around her ankles, her breasts exposed as well. She had a hold of (R1's name) trying to put his hands in her crotch. He was trying to pull away from her. This writer asked (R1's name) if he would like to come sit in the lobby, TV room, he got off the bed and came with this writer. 01/25/19 11:44 a.m. The past few weeks: resident has been followed and led around by another resident from the west hallway, . (R2's name) has been found in residents' room with her top pulled up over her head and her bra off .exposing a naked body. This has repeatedly happened and resident does not appear to be actively involved but rather coached into what he should be doing. One incident resident was found completely naked with his hands down (R2's name) pants and her hands guiding him to fondle her. It is my professional and personal opinion that the behaviors and actions of (R2's name) are inappropriate and not wanted by resident. He does not appear to be a willing participant. This behavior from (R2's name) is happening more and more frequently. Written by RN A. The facility to this point had allowed a sexual relationship between R1 and R2 without having assessed either resident's ability to consent to such a relationship. On 06/25/19 at 9:40 a.m., SW H indicated she reached out to the regional ombudsman a few months ago and received information about the resident's ability to consent to a sexual relationship. After receiving the information, the IDT met and determined that R1 was not able to consent to sexual activity. SW H indicated the care plan was adjusted at that time. The care plan was updated for R1 on 02/12/19 stating, in part, Resident has developed a relationship with a female resident at facility. Facility staff need to allow resident to maintain this connection and spend time with the female resident, but also ensure safety .resident does not have the ability to consent to physical/sexual contact with the female resident. R2's care plan was not updated until after the self-reported incident on 05/03/19. The updated care plan in part, Potential for inappropriate behavior .Provide and maintain safety and wellbeing to resident .intervene when residents are attempting to seek one another out. Do not allow to spend time together alone . On 06/25/19 at 1:40 p.m., Surveyor interviewed SW H and asked why R1 had been care planned and considered competent until 02/12/19. Surveyor asked why R2 was not assessed as incompetent to consent to a relationship until 05/03/19. SW H indicated the previous direction she had gotten stated they were to allow the residents to have the relationship regardless of ability to consent Surveyor interviewed the ombudsman on 06/13/19 prior to the survey. The ombudsman indicated she had spoken with the social worker in (MONTH) 23, 2019 about sexual relationships and gave SW H resources for a sexual intimacy policy, sexual risk history and ability to consent assessment criteria. The ombudsman stated she stressed to the Social Worker the importance of residents being competent to consent to having a sexual relationship as the first step. The ombudsman shared the resources with the Surveyor. The material is educational information on sexual intimacy provided by the Wisconsin Board on Aging and Long-Term Care Ombudsman Program. The material in part: Appendix 2- Recommendations for addressing Resident relationships Assessment for consent to physical sexual expression in part: .Assessment efforts should focus on the resident revealing his/her understanding of the following four guidelines: 1. The person understands the distinctively sexual nature of the conduct. 2. The person understands that their body is private and they have the right to refuse, or say 'no'. They should also understand the other person should respect their right of refusal. 3. The person understands there may be health risks associated with the sexual act. ([MEDICAL CONDITION], cardiac issues, other health risks (falls). 4. The person understands there may be negative societal response to the conduct. (Gossip, name calling, social fallout, stigmatized.) Definitions - Sexual contact - the meaning of sexual contact for this policy is derived from the Wisconsin Sexual Assault statute. A facility's regulatory obligation to protect vulnerable residents from any form of abuse and the legal implications related to ability to consent are paramount when discussing sexual relationships. Paraphrased from WI statute section 940.225(5) (b), sexual contact includes intentional touching of intimate body parts, either directly or indirectly through clothing by the use of another body part or object for the purpose of sexual arousal, gratification, degradation or humiliation. Consent- there are no definitions in Wisconsin Statutes that address the issue of consent as it relates to sexual contact in anything other than the context of criminal activity. Consent, as used in the Sexual Assault section in the Wisconsin Statutes, means words or overt actions by a person who is competent to give informed consent indicating a freely given agreement to have sexual intercourse or sexual contact. The statute goes on to say, the following persons are presumed incapable of consent but the presumption may be rebutted by competent evidence: A person suffering from a .defect which impairs capacity to appraise personal conduct .'the ability to evaluate the significance of.' R1's social service progress note dated 02/12/19 indicates, .contacted resident's spouse/POA-HC .discussed resident's relationship with another female resident in facility, and resident's Brief Cognitive Assessment Tool (BCAT) assessment and this assessment indicating that resident had severe dementia .indicating that resident was not capable of consenting to physical/sexual contact .SW stated the facility could not provide 24 hour care, 1:1 .but there was a potential that resident and the female resident could be alone together .SW stated resident and the female resident could have physical or sexual contact despite the staff's best efforts to monitor this . R1's nursing notes indicate: 05/03/19 Writer was called to resident's room by CNA (CNA F) that a west resident was in (R1's name) room .she was fully naked and (R1's name) was naked from the waist down. Both residents were redressed .(R1's name) did not make sense and did not understand what just happened. The two were separated . The regional office received a facility reported incident regarding potential sexual abuse between R1 and R2 that occurred on 05/03/19. On 06/25/19 during the onsite investigation at 7:50 a.m., Surveyor observed R1 wandering around in his room. At 8:00 a.m., Surveyor interviewed R1 to determine his understanding of the relationship with R2. Surveyor asked R1 if he knew what day or time it is. R1 only mumbled in response. Surveyor asked if R1 knew R2. R1 replied, I don't know where. Surveyor asked if R1 was in a relationship. R1 replied, Where were they? Surveyor asked R1 if he is married. R1 replied, I don't think so. R1 is unable to respond with any answers that are sensible to the questions being asked. Surveyor observed R1 walking independently out of his room and down the hall. At 8:10 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) F, who was the witness to the 05/03/19 event. CNA F described the relationship between R1 and R2, indicating R2 pushes it, trying to hold R1's hand and follow him. CNA F indicated R1 has no understanding of what is going on. Surveyor asked how long CNA F has been making these observations. CNA F stated for several months. Surveyor asked for specifics for the 05/03/19 incident. CNA F stated, It was near lunch time. CNA F saw R1's door was shut when she went in to get R1 for lunch. CNA F said she opened the door to see R2 completely undressed. R1 was sitting on the edge of his bed. R2 was bent over taking off R1's pants. CNA F stated R1 was naked from the waist down, with his pants by his ankles at this time. Surveyor asked what kind of touching was observed. CNA F indicated R2 was touching R1's lower body as she was undressing him. CNA F redirected them, and reported the observation immediately to her supervisor as other staff helped the residents dress. At 8:13 a.m., Surveyor interviewed CNA [NAME] about the above relationship. CNA [NAME] stated they are together all the time. R1 rubs R2's back. Surveyor asked if they are ever alone together. CNA [NAME] indicated that she has never seen them alone together and keeps R1's door open. At 8:20 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) B, who stated the residents always look for each other. Staff try to redirect R2 and keep her from coming down this hall (where R1 resides). Surveyor asked if R1 and R2 were ever allowed to be alone together or found together other than 05/03/19. LPN B stated, It has happened more than once. I've heard about it, but I didn't see it. At this time, they can only be in commons area together. At 8:43 a.m., Surveyor interviewed the Director of Nursing (DON) about the relationship. Surveyor asked if she was aware of any other incidents of the residents being alone together. The DON indicated the only time was in May. At 9:14 a.m., Surveyor interviewed Registered Nurse (RN) G, who was in charge on the floor on 05/03/19. RN G recalled a CNA coming to her to report the residents had been found together, R1 with his pants down and R2 completely undressed. Surveyor asked about incidents prior to this date. RN G stated she started to work at the facility on 09/18/18, and indicated the residents had a relationship then. RN G stated, At this time, they are only allowed together in the commons area. Surveyor asked what interventions were in place to direct the staff regarding R1 and R2's interactions. RN G stated, The care plan stated they were to be left alone if they wanted sexual intimacy. Surveyor asked if any other observations of sexual activity had occurred. RN G stated, I don't know. Surveyor asked if Social Worker (SW) H was aware of this. RN G stated, Yes it was care planned to be that way. Surveyor asked RN G if R1 could give consent for the sexual activity. RN G said, No. Surveyor asked if the facility has a system in place to determine if the residents are able to consent to sexual relationships. RN G stated, No. At 9:25 a.m., Surveyor interviewed LPN C about the relationship. LPN C indicated R2 would frequently go into R1's room and hold R1's hand. Surveyor asked if the relationship was sexual. LPN C stated they would touch each other when in R1's room. LPN C stated, Now we have been told to keep them in commons area, they cannot be alone in a room. At 9:32 a.m., Surveyor interviewed CNA D about the relationship. CNA D indicated R1 and R2 can only be in the common areas together. Surveyor asked if CNA D was aware of the residents being alone together or having any sexual relationship. CNA D stated, No. CNA D indicated they have been educated to keep them in commons area, and that they cannot be alone together. On 06/25/19 at 9:35 a.m., Surveyor observed R1 and R2 in the activity area. R1 was holding R2's hand as she sat in the wheelchair. At 9:38 a.m., Surveyor observed R1 walking down to the east hall, with R2 walking with her walker behind him. Staff came and redirected R2 to another direction. On 06/25/19 at 9:40 a.m., Surveyor interviewed Social Worker (SW) H asking about the facility process for assessing for the ability to consent to a sexual relationship. SW H stated, We do not have a specific sexual assessment. Surveyor asked if the facility obtains a sexual history of residents to determine what the intimacy needs are. SW H stated they did not do this for R1 and R2. Surveyor asked if R1 and R2 had been found alone in a compromising position at any other times. SW H replied, I don't think so. On 06/25/19 at 11:30 a.m., Surveyor asked the Nursing Home Administrator (NHA) if any investigations had been done for the incidents on 01/13/19 and 01/23/19. The NHA stated he was not in this position at that time but would look. At 11:50 a.m., Interim Nursing Home Administrator (INHA) came to the surveyor with questions as to why the concern was so serious when the residents showed no outward signs of distress. INHA referred to the self-report investigation that included in part, Neither resident showed any sign or symptom of emotional, physical or psycho-social distress .both were noted as being o.k. with the incident . Surveyor stated the reasonable person concept has to be considered with a person with dementia. The residents cannot remember the incident due to their cognitive deficits so would not be able to have a normal response. Surveyor stated the residents with dementia have fluctuating mental awareness so what might be yes now to hand holding, may be fearful and a no response tomorrow. A reasonable person who was lying in bed and had another person come in to their room and remove their clothing and then take off their own clothing would most likely have psychosocial distress and outcome from this incident. On 06/25/19 at 1:30 p.m., the NHA indicated the facility had no investigations into the incidents in January. The facility self-report on 05/03/19 regarding R1 being found naked with R2 was reviewed by Surveyor. The investigation did not contain any staff interviews or additional details to the extent of the sexual contact that may have occurred. The self-report in part, CNA F reported on 5-3-19 approximately 11 a.m. entering (R1) room to find him sitting on the edge of his bed naked from the waist down. Resident (R2) was standing next to bed fully nude. RA intervened immediately by asking both residents to get dressed. Nursing staff were contacted to assist residents with dressing .Both residents were interviewed regarding the incident. (R1) and (R2) have a mutual relationship with one another. Both were noted as being ok with the incident. Both residents are comfortable with one another and do spend time together within the facility common areas. We continue to monitor .for any negative outcomes, which are not apparent as they both enjoy each others company . Surveyor requested the staff training on abuse and sexual abuse. The facility had educated all staff on sexual abuse and definition of consensual sexual activity with definitions. The last employee education was completed on 06/06/19. The facility's failure to protect vulnerable residents from sexual abuse created a finding of immediate jeopardy. The immediate jeopardy was removed and corrected on 06/06/19 after the facility completed education on sexual abuse and definitions of residents' ability to consent to sexual activity for all staff and supervision was implemented to prevent residents from being alone together unsupervised. The deficient practice is being cited as past noncompliance.

Based on observation, interview and record review, the facility did not ensure a resident who entered the facility without a pressure injury did not develop a pressure injury; and a resident with a pressure injury receives the necessary treatment and wound care to promote healing and prevent infection. This occurred for two of three sampled residents with pressure injuries (Residents (R) 40 and 21). The first example rises to a G level. The additional example is at a D level. R40 developed an unstageable pressure injury to the left heel. The facility did not follow current standards of practice for repositioning, offloading, and the prevention of pressure injuries, in which the resident is no longer able to ambulate due to the wound. The facility did not perform wound care in a hygienic manner for R40, and the wound was not assessed and measured every seven days. The resident's care plan was not updated to identify the resident's current pressure injury. R21 is at high risk for pressure injuries on her feet. The facility did not develop or implement a plan of care to prevent an avoidable pressure injury on R21's right inner heel. R21 was observed in bed with her right heel pressing directly on her mattress, without the prescribed boot. R21's wound care was provided by a nurse who did not ensure that aseptic technique was followed to prevent infection. The facility did not update R21's care plan to address the presence of R21's pressure injury. This is evidenced by: According to the National Pressure Ulcer Advisory Panel (NPUAP) standard of practice, .Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that heels are free of the surface of the bed Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf . (NPUAP Heel Pressure Ulcers: 2014 International Pressure Ulcer Prevention & Treatment Guidelines, 2014). 1. On 03/06/18, Surveyor reviewed R40's medical record. The resident has [DIAGNOSES REDACTED].' caused by infection). The resident's Brief Interview for Mental Status (BIMS) score, dated 02/12/18, was a 09 out of 15 possible points. According to the BIMS assessment, a score of 09 indicates the resident has moderately impaired cognitive function. R40's Minimum Data Set (MDS), dated [DATE], identifies the resident is at risk for developing pressure injuries. On 01/20/18, R40 rolled out of bed. At this time, the facility placed a foam perimeter mattress (mattress with raised edges) on the resident's bed to prevent R40 from rolling out. Surveyor reviewed R40's Skin and Body Assessment, dated 01/29/18. The assessment identifies the resident has no areas of skin breakdown, or redness on either heels. The resident's nurses' notes, from 02/20/18 to 03/07/18 were reviewed. The notes state the following, in part: -02/21/18: Requires one aide assist for bed mobility to provide extremity movement assist .Bed mobility has not changed .Requires one aide assist to walk in room .is not resistive to cares . -02/22/18: Is independent in moving about the unit. Primary mode of locomotion is with a wheelchair . There no documentation in the notes the resident digs his heels in the floor when self-propelling in the wheelchair. Surveyor reviewed R40's current comprehensive care plan. The care plan states the following, in part: .02/13/2017 PROBLEM: Potential for Tissue integrity impairment .RELATED TO: [MEDICAL CONDITION](stroke) falls, inconinence (sic) .MANIFESTED BY: Moist areas .APPROACH 02/13/2017 Nurses--- Follow medical plan for treatment, Keep MD (Doctor of Medicine) informed, Assess nutrition stat. (status) Assess skin status .Nurse Aide--- Keep skin clean and dry, Encourage and assist to reposition, Inspect skin daily .GOAL 01/30/2018 Adequate fluid intake, skin remains intact . 03/17/2017 PROBLEM: Self Care Deficit .RELATED TO: unable to ambulate independently .APPROACH .09/06/2017 Restorative--- Ambulate resident 50-100' with FWW (Four-Wheeled Walker), CGA (Contact Guard Assist) WC (Wheelchair) to follow for safety 1-3 x (times) daily as tolerated . The care plan does not identify the resident is at risk for skin breakdown due to the resident digging his heels in the floor when self-propelling in the wheelchair. Surveyor reviewed R40's restorative documentation, from 01/02/18 to 02/24/18. The documentation identifies the resident was walking with the assistance of staff in the resident's room, and in the hallway, approximately one to four times a day when R40 was able. R40's medical record contains a physician's orders [REDACTED]. Duoderm. Change q (every) 5 days and PRN (as needed) .off loading boots while in bed, consult for new diabetic shoes . The facility sent a fax to the resident's physician, on 03/02/18, which states in part, .Situation: Left heel Deep Tissue Injury (DTI,see description below). Presents as intact skin, raised, serum filled (clear fluid) .discolored area measuring 6cm (centimeters) x 4cm .Background: Resident is known to dig heels in the floor when in w/c. This is a pressure & shear related injury .Request: OT (Occupational Therapy) to screen for w/c appropriateness. Tx (Treatment) Cleanse (with) saline. Apply barrier wipe. Cover with [MEDICATION NAME] Foam dressing, wrap (with) Kerlix, change every 3 days and PRN . A DTI is a pressure-related injury to a person's subcutaneous tissue under intact skin. This type of pressure injury has the appearance of a bruise below the surface of the skin. It is noted, there is no documentation in the resident's nurses' notes of the DTI, or how this injury may have occurred to the left heel, from 02/27/18 to 03/12/18. The medical record identifies R40 is non-weight bearing on the left foot due to the wound, as of 02/27/18. The documentation identifies the resident is not allowed to ambulate in the hallway with staff for restorative care in order to promote healing and prevent further breakdown of the heel. The resident's inability to ambulate may result in the resident's reduction in muscle strength and muscle mass, reduced bone demineralization, reduced bladder capacity, decreased skin integrity, and an increase in falls. R40's current care plan does not identify the presence of the DTI on the left heel, and the resident is non-weight bearing on the left foot. On 03/06/18 at 2:02 p.m., Surveyor observed R40 lying in bed on his back. The resident was wearing a blue Podus-style padded boot on the left foot, resting directly on the mattress. The resident's right foot was not wearing a boot or shoe, and the right heel was resting directly on the bed. On 03/07/18 at 6:46 a.m., Surveyor observed R40 lying in bed on his back. The resident was wearing a blue Podus-style padded boot on the left foot, resting directly on the mattress. The resident's right foot was not wearing a boot or shoe, and the right heel was resting directly on the bed. At 7:28 a.m., R40 was lying in bed on his back. The resident was wearing a blue Podus-style padded boot on the left foot, resting directly on the mattress. The resident's right foot was not wearing a boot or shoe, and the right heel was resting directly on the bed. On 03/08/18 at 9:36 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) J. CNA J stated the resident wore diabetic shoes while up in the wheelchair, prior to the resident obtaining the DTI. The CNA stated the resident has always used his feet to self-propel the wheelchair, which is nothing new for the resident. Surveyor asked if R40 wore any type of preventative boot while in bed, or if the resident's heels were floated while lying in bed prior to 02/27/18. CNA J stated R40 did not wear any boots, and the staff did not float the resident's heels when in bed. During the continued interview, CNA J stated after R40's DTI was found, the resident wore a Podus boot on the left foot only at night while in bed. The CNA further stated staff later noticed R40's left foot was down on the floor while up in the wheelchair, so the facility had the resident wear the Podus boot during the day. The CNA indicated the resident was walking with staff almost daily, in R40's room and in the hallway. The CNA stated R40 is now a pivot transfer and no longer ambulates due to the wound on the left heel. At 1:03 p.m., Surveyor interviewed CNA G. The CNA stated the resident has never had his heels floated in bed, and has always had his heels resting on the mattress, prior to the discovery of the DTI. CNA G stated R40 has always crossed his feet in bed when he sleeps, and the left foot was always on the bottom resting on the bed. Surveyor reviewed R40's CNA care plan, which was in place prior to 02/27/18. The care plan does not instruct staff to float the resident's heels with pillows, or for the resident to wear any type of preventative boots in bed. The care plan does not identify the resident digs his heels into the floor when self-propelling the wheelchair. At 1:52 p.m., Surveyor asked the Director of Nursing (DON) how the resident's left heel DTI was obtained. The DON stated the resident's wheelchair was too low, which caused the resident to dig his heels into the floor when the resident propelled the wheelchair. The DON explained after the DTI was identified, the facility obtained the OT evaluation, and the resident's wheelchair was changed. The OT progress notes for R40 state the following, in part: -02/27/18: . Skilled interventions include Clothing management associated with toileting, Establishing and maintaining safe posture during toileting, Training in safe and effective technique in transfer to and from toilet and Training in hygiene tasks associated with toileted. Skilled interventions include establish and maintain safe posture during hygiene/grooming and Training in compensatory strategies to improve performance in hygiene/grooming activities. -02/28/18: .Upon arrival therapist noticed padded on L (Left) foot, therapist discussed WB (Weight Bearing) on foot with RN (Registered Nurse). RN stated there was .large are(a) on L heel and recommended to stay seated during therapy . -03/02/18: .Activity modifications recommended as patient now has new weight-bearing precautions on left foot due to new wound. The therapy progress notes provided to Surveyor do not identify any OT evaluation issues or new interventions related to the wheelchair, in order to prevent the resident's heels from digging into the floor. At 3:18 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) E, if staff floated R40's heels, prior to the resident obtaining the DTI. LPN E stated staff did not float the resident's heels when resident was lying in bed, prior to the presence of the left heel wound. On 03/08/18 at 3:08 p.m., Surveyor observed R40's dressing change to the left heel wound. The resident was lying in bed on his back. The resident was wearing a new AFO (type of brand) brace on the left foot, which has a hard sole and back in which the heel was suspended. The resident's right foot was not wearing a boot or shoe, and the right heel was resting directly on the bed. At this time, LPN E went into the resident's bathroom and washed her hands, and removed two clean gloves out of a box in the bathroom. The LPN walked to the resident's closet, opened the door by the handle, pulled out a clear, plastic storage bag with dressing supplies, and closed the closet door by the handle. Surveyor observed LPN E walk over to R40's bed, place the storage bag on the resident's bed without a barrier below the bag, near the resident's feet. The LPN was holding the clean gloves in her left hand. The LPN then put the gloves on both hands, and pulled R40's cloth privacy curtain with LPN E's left hand. LPN E was observed to pull back the resident's personal blanket, which was touching the top of R40's feet. The LPN then used her gloved hands to remove the Velcro straps from the boot on the resident's left foot. The LPN then touched the bottom of the boot with her left hand and removed the boot from the resident's foot. LPN E then removed the resident's sock from the left foot. With the same gloved hands, LPN E lifted R40's foot by the ankle and placed a towel below the heel as a barrier, and placed the foot on the towel. Surveyor observed R40's wound on the bottom of the left heel. The entire wound appeared to be irregularly shaped, was black and intact. The outer, top edges of the wound appeared to be dark red (looked like blood beneath the skin), and the areas around the reddened areas were yellow. The wound appeared to extend to the outside of the resident's heel/foot, and was black. At this time, LPN E was observed to reach into the storage bag with the same gloves and pulled out a pair of scissors which was used to cut off the resident's old dressing, and the LPN placed the scissors back into the bag of wound supplies. LPN E removed the resident's dressing from the left foot and placed the dressing into a garbage container. The LPN did not remove her gloves and wash her hands prior to touching the scissors, or removing the resident's dressing after touching multiple unclean items, listed above. LPN E did not sanitize the scissors prior to using them to cut off the dressing, or cutting off the old dressing and placing the scissors back in the storage bag with the wound supplies. Surveyor observed LPN E reach into the storage bag, pull out a small tube of saline, and the tube was opened. The LPN pulled out a piece of gauze from the bag with the left glove, and poured the saline onto the gauze. LPN E then raised R40's foot by the ankle, and wiped the gauze pad onto the left heel and inside of the heel with the saline gauze pad. LPN E then reached into bag, pulled out a pad of skin protectant, lifted the resident's foot by ankle and placed the protectant on the left heel. Surveyor observed LPN E reach into the bag with the right hand and pull out a package of the [MEDICATION NAME] dressing and used this package to fan and dry off the protectant on the left heel. LPN E still had not changed gloves or washed her hands since the start of this observation. At approximately 3:20 p.m., LPN E opened the [MEDICATION NAME] dressing packet, and placed the dressing onto R40's left heel. The LPN reached into the bag, pulled out a packet of rolled gauze, opened the package and touched the gauze, and wrapped the resident's heel and top of the foot. The LPN then reached into the storage bag, pulled out the same scissors and cut the new gauze. LPN E did not sanitize the scissors since cutting off the resident's old dressing. LPN E then removed the tape roll from the storage bag, removed her gloves, and applied strips of tape to the dressing. Surveyor then observed the LPN place the sock back on the resident's left foot, as well as the foot brace. LPN E then went into the bathroom and washed her hands. This is the first time LPN E washed her hands, since the start of the wound care observation. At 3:30 p.m., Surveyor informed the DON of the above wound care observation. The DON stated she would have expected LPN E to change gloves and hand wash after touching unclean items like the privacy curtain and the resident's boot; and after removing the old dressing, cleaning the wound and before applying the new dressing. On 03/12/18 at 9:44 a.m., Surveyor asked the DON for the resident's current DTI measurements. The DON stated she came to facility on 03/11/18 to assess and measure the resident's wound. The DON informed Surveyor R40's left heel wound is now an unstageable pressure injury with the presence of black eschar (dead tissue). There are no wound measurements in the resident's medical record, between 03/01/18 and 03/11/18. The facility's policy is to measure and assess the wound every seven days. On 03/11/18, the wound measured 5 cm by 3.5 cm. According to the facility's Skin Treatment Management Guidelines policy, revised (MONTH) (YEAR), an unstageable pressure injury is defined, in part: .Unstageable Pressure Injury .Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (yellow or creamy tissue) or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . According to the manufacturer's guidelines, provided to Surveyor by the facility, of R40's current perimeter mattress, this mattress should be used for residents who may have a stage I or up to a stage II pressure injury. At 9:47 a.m., Surveyor interviewed R40. The resident stated prior to obtaining the heel wound, his heels were not floated up on pillows, and rested directly on the bed. The resident indicated he walked pretty good, prior to the wound, but is unable to walk now. Surveyor asked R40 how the resident feels now that he is unable to walk, to which the resident replied, It makes me sad .like I lost my independence .I just can't do anything. At 12:30 p.m., Surveyor asked the DON if she has considered obtaining an air mattress for R40. The DON replied she wanted to see if the new AFO boot (which the resident received on 03/08/18) promoted the wound to heal before pursuing an air mattress for the resident's bed. Surveyor asked if the resident's heels were floated prior to the DTI appearing. The DON replied the resident's heels were not floated while in bed, because the resident is at an increased fall risk, and pillows have never been placed in the resident's bed because of this risk. The DON stated this is not documented in the resident's medical record or care plan. The DON stated the resident has not been care planned to ever have his heels floated. During the continued interview, the DON stated the resident's pressure injury was not caused by R40's heels not being floated in bed but by the resident digging his heels into the floor when propelling the wheelchair. The DON stated OT evaluated R40's wheelchair after the DTI was discovered, and OT obtained a thinner wheelchair cushion so the resident could place his foot flat on the floor. The DON stated the resident spends most of his time up in the wheelchair. Surveyor reviewed R40's fall assessment, dated 01/29/18. The fall assessment identifies the following, in part, .If the resident has had previous fall(s), did environmental or situation factors contribute to the fall? No . The assessment does not identify the presence of having pillows in the bed will increase the resident's fall risk. At 1:11 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) and the DON. Surveyor asked if the facility measures resident wounds every seven days; to which the DON stated she tries to measure the wounds every week. The DON further stated there are times in which she is not able to measure wounds every week, due to working different shifts in the facility. Surveyor discussed the interview with CNA G, in regards to R40 crossing his legs while in bed. At this time, Surveyor asked the DON if she was aware the resident crossed his legs while lying in bed, to which the DON replied, I did not know for sure. During the continued interview, the DON confirmed R40 is currently a pivot transfer with staff assistance, and is non-weight bearing on the left foot due to the wound. Surveyor asked if the NHA or DON noticed if the resident dug his heels into the floor prior to the presence of the DTI. The NHA and the DON did not answer or comment. Surveyor informed the NHA and DON that R40's care plan does not currently identify the resident as having a pressure injury to the left foot. The DON stated MDS Coordinator B is responsible for updating resident care plans. At 1:59 p.m., Surveyor observed resident lying in bed on his back. The resident's right foot was not wearing a boot or shoe, and the right heel was resting directly on the bed. The following example is cited at a level D - potential for harm/isolated. 2. R21's medical record states that she has [DIAGNOSES REDACTED]. R21 is assisted by staff to complete her personal care needs, and is transferred using a sit-to-stand lift. R21's MDS states that she is at risk to develop pressure injuries. A fax was sent to Nurse Practioner (NP) H on 02/05/18 which states, Resident presents with a Stage 1 Pressure Injury right inner heel. Measures 3.5 cm (centimeters) X (by) 3 cm .Assessment/Appearance: non blanchable redness .Request: Rt (right) heel: cleanse c (with) saline - Apply barrier wipe. Cover c [MEDICATION NAME] Dressing (Duoderm) change every 5 days & PRN (as needed) until healed Prevalon boots on when in bed. No shoes until healed. NP H's response was, As above. Measurements and descriptions for the pressure injury are documented as follows. 02/05/18 - 2.5 by 2 cm Presence of pain: yes. Healing process: nonblanchable redness to ankle. 02/13/18 - 2.5 by 2 cm Presence of pain: yes .nonblanchable redness. Defined edges. 02/23/18 - 2.5 by 2 cm Presence of pain: no .Area now blanchable redness. 02/28/18 - 2.0 by 1.8 cm Presence of pain: no .Blanchable redness still present. On 02/12/18, a Podiatrist saw R21 and cut her toenails. The Podiatrist described R21's feet as: Skin color: Pallor Temperature: Cool Dorsal Pedis Pulse: Absent Posterior Tibial Pulse: Absent [MEDICAL CONDITION]: Nonpitting Hair Growth: Absent Increased distal cooling: Yes Capillary Filling Time: Delay 5 seconds Epicritic sensation: Diminished Parasthesias: Yes Burning: Yes (unreliable response) [MEDICAL CONDITION]: Yes The Podiatrist also stated that R21's podiatric [DIAGNOSES REDACTED]. The above information predisposes R21 to the development of pressure injuries on her feet. On 03/06/18 at 1:55 p.m., Surveyor interviewed R21 while she was in bed. R21 stated, I have a sore on the bottom of my heel. I have salves to put on it. The people here do that. R21 stated that her heel hurts, especially when she steps on it in the sit-to-stand lift. R21 had a boot on the left foot. R21's right foot was wearing a gray gripper sock. There was no boot on right foot, and it was pressing against the mattress. There were no pillows near R21's feet. R21 held up her right foot and again said, There's a sore on this foot. Although the above pressure injury was discovered on 02/05/18, as of 03/08/18, it was not mentioned on R21's care plan. R21 did have a care plan addressing the potential for tissue integrity impairment, related to Incontinence and needs staff for ADL (activities of daily living) tasks manifested by advanced age, loss of bladder control, dementia. There was no instruction to have staff float R21's heels on this plan of care. On 03/08/18 at 1:30 p.m., Surveyor observed LPN A perform wound care for R21. R21 was lying on the bed on her back. R21 had blue boots on her feet. The wound care supplies were placed on two paper towels on R21's tray table. LPN A washed her hands and brought gloves from the bathroom and placed the gloves on the tray table, on an activity calendar, touching R21's hand splint and her comb. LPN A donned the gloves and asked the resident, Which foot is the owie one? R21 moved her right foot. R21 had a bunched-up [MEDICATION NAME] Pillow Pet under her left lower leg. LPN A took off both of the boots. The left heel was intact. Surveyor asked LPN A when was the last time she saw the heel. LPN A stated, I haven't. I'm a floating nurse, and usually afternoons (p.m. shift) does this. LPN A moved R21's left leg and R21 stated, Ouch, that hip. Surveyor asked LPN A when R21 had her last pain medication and LPN A stated, She had [MEDICATION NAME] at noon. R21's right heel had a thin [MEDICATION NAME] over the pressure injury. LPN A removed the old [MEDICATION NAME], walked to the bathroom and stated, I need more gloves. LPN A washed her hands and brought gloves to tray table placed them on same place, again touching R21's comb. R21 said, I don't know what to do when this heel hurts so bad when LPN A was in the bathroom. LPN A opened a container of normal saline, and wet some gauze. LPN A then donned gloves from the tray table, touched the left boot to move the left foot away, lifted the right foot with her left hand, and cleansed the area using her right gloved hand. LPN A then put the right foot back on the bed. LPN A was wearing the same gloves, and then dried the wound with dry gauze, and placed the heel on the bed. While wearing the same gloves, LPN A applied skin prep to the periwound. The area appears to be a blister which is reabsorbing. R21 stated, Ow it hurts. Wearing the same gloves, LPN A applied the clean dressing, which was a thin [MEDICATION NAME]. Surveyor asked how often the dressing is changed, and LPN A stated, I'll have to check that. I don't know that off the top of my head. LPN A put R21's sock and boot back on her right foot. R21 said, Ow. Surveyor asked R21 if she has pain in the heel, and R21 stated, My heels hurt when I step on them. LPN A stated, She doesn't walk. R21 does stand several times a day in the sit-to-stand lift. LPN A put away the supplies and then washed her hands. After the observation, Surveyor talked to LPN A regarding not removing gloves and washing hands after cleaning the wound, and before applying skin prep and the clean dressing. Surveyor discussed the observation with the the Director of Nursing (DON), on 03/08/18 including placing the clean gloves on the tray table, touching items before they were donned. Surveyor asked the DON if the facility does daily diabetic foot inspections. The DON told Surveyor at 2:55 p.m. on 03/08/18 that R21's pressure injury developed because staff was not floating her heels. The DON stated that she has added that night staff will reposition R21 more frequently. Boots were put on R21's feet after the pressure injury was discovered. During this interview, the DON stated that the nurses do not inspect the feet of the diabetic residents on a daily basis, but cut toenails of the diabetic residents weekly, and the CNAs (Certified Nursing Assistants) are trained to look at residents' feet daily and to report anything unusual. Surveyor interviewed the DON on 03/12/18 02:06 PM and discussed the above concerns. The DON expressed understanding of the importance of preventing pressure injuries.

Based on observation, staff interviews, and record review, the facility did not provide the necessary care and services to ensure 2 (Residents #5 and #2) of 12 sampled residents attained or maintained the highest practicable physical, mental, and psychosocial well-being when adequate pain control was not provided. Staff did not anticipate, recognize, evaluate, or manage Resident #5's pain during an observation of personal hygiene cares and pressure ulcer treatments. Staff did not anticipate, recognize, evaluate, or manage Resident #2's pain during an observation of personal hygiene cares and pressure ulcer treatments. This is evidenced by: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's Minimum Data Set (MDS), dated [DATE], indicated that Resident #5 required extensive assistance for bed mobility, transfers, and hygiene. In addition, this MDS indicated that Resident #5 did not ambulate, had frequent pain rated at 7 on a scale of 1-10, and was frequently incontinent of bowel and bladder. On 05/06/14 at 8:25 a.m., Surveyor observed Resident #5 in his room being assisted with breakfast. Licensed Practical Nurse (LPN) Q was in the hallway near Resident #5's room and reported, "I give (Resident #5 and Resident #2) pain pills before their cares are performed." On 05/06/14 at 10:50 a.m., Surveyor observed a.m. cares being provided with Resident #5. Throughout cares, Resident #5 moaned as he was moved during cares. At 11:00 a.m., Surveyor observed Resident #5's facial expressions becoming a grimace when resident was rolled from side to side while his pants were being put on and his socks and podus boots were reapplied. Surveyor observed Certified Nursing Assistant (CNA) N continue performing personal cares when Resident #5 complained of pain, grimaced and/or winced. When observation of cares was complete, Surveyor asked Resident #5 if he was able to rate his pain on a scale of 1-10. Resident #5 responded, "It's probably a 10." Resident #5 declined to get out of bed after cares were complete and reported to CNA N, "I am too exhausted and in pain to get up for lunch." At 12:00 p.m., Surveyor interviewed LPN Q. Surveyor asked what time Resident #5 recieved his pain pills. LPN Q responded, "At 7:30 a.m." LPN Q went on to say, "Did he complain of pain again?" Surveyor reported the above observation to LPN Q who then went to her medication cart and retrieved medication. At 12:10 p.m., Surveyor observed LPN Q enter Resident #5's room stating, "I have pain pills for you, you should love me." Surveyor asked LPN Q what medication she was giving Resident #5. LPN Q responded, "Two [MEDICATION NAME]. He can have them every six hours." Review of Resident #5's document titled "Physician order [REDACTED]. [MEDICATION NAME] 500 mg tablet dose ordered: (1 tablet/500 mg) by mouth every 4 hours as needed FOR: pain [MEDICATION NAME] HCI 5 mg tablet dose ordered: (0.5 tablet/2.5 mg) by mouth every 12 hours as needed FOR: Moderate to Sever pain. Give [MEDICATION NAME] first, only give this for severe pain. [MEDICATION NAME] HCI 50 mg tablet dose ordered: (1 tablet/50 mg) by mouth every 6 hours as needed FOR: (Moderate to Moderately Severe Pain) Administration Instructions: Give before [MEDICATION NAME]." On 05/06/14 at 2:00 p.m., Surveyor observed the Director of Nursing (DON) perform Resident #5's pressure ulcer treatment to bilateral heels. During the dressing change, Resident #5 winced when the DON touched his right and left heel. Resident #5 also complained of pain accompanied by facial grimacing when the dressings were changed to his heels. When the treatment was completed by the DON, Resident #5 rated his pain at a 4-5 on a scale of 1-10. Resident #5's plan of care, dated 03/26/14, titled "Comfort, Alteration: Related to: recent fall with vertebral fractures. Identified Approach: Nurses -- Monitor pain characteristics: Administer pain meds, Monitor/record: med effectiveness, med side effects, Notify MD (medical doctor) prn. Nurse Aide --position for comfort, Assist with repositioning, assist with ADLs as needed, Report pain to nurse, Goal: Resident will say his pain is at a 3 or less following pain interventions." On 05/12/14, Surveyor was provided a copy of documentation that identified Resident #5's pain assessment. assessment dated [DATE] read in part as follows: "Pain: pain present Intensity of pain: moderate Quality of Pain: sharp burn ache Manner of Expressing Pain: Verbal: 9/10 Effects of Pain: Physical Activity: Does not do much physical activity because of the pain. Appetite: Decreased appetite. Concentration. No concentration when pain is at its worst. Current medications: [REDACTED] Response to Treatment: Responds well to medication." Continuation of documentation dated 04/01/14 read in part as follows: "Note: MDS pain assessment How much of the time have you been experiencing pain or hurting at any time in the last 5 days: Frequently Please rate your worst pain over the last 5 days on a zero to ten scale: 7 Current medications: [REDACTED]." Continuation of documentation, dated 04/23/14, read in part as follows: "Been on a Scheduled Pain Medication Regime: No (with a hand written undated, unsigned note that read: d/c'd due to side effects.) Indicators of pain or possible pain: Vocal complaints of pain (that hurts, ouch stop), facial expressions (grimaces, winces,) Pain: Days Negative Vocalization: repeated trouble calling out, moaning, groaning, or crying Facial Expression: grimacing, Consolability: Unable to console, reassure or distract" Hand written note, unsigned and documented above documentation, dated 05/10/14, read as follows: "received orders on 05/07/14 for scheduled pain med." Continuation of documentation, dated 05/10/14, read in part as follows: "Did respond that he had thriving pain when asked about his pain. Is at a wedding anniversary party for themselves today." On 05/08/14 at 1:15 p.m., Surveyor interviewed Resident #5 asking if it helps with the pain when they give him a pain medication before personal cares and/or changing his dressings. Resident #5 responded, "Yes it helps." 2. Resident #2's MDS, dated [DATE], indicated that Resident #2 required extensive assistance for bed mobility, transfers, and hygiene. In addition, this MDS indicated that Resident #2 did not ambulate, had occasional pain rated at 3 on a scale of 1-10, and was frequently incontinent of bowel and bladder. On 05/06/14 at 11:30 a.m., Surveyor observed a.m. cares being provided with Resident #2. At approximately 11:40 a.m., Resident #2 stated, to CNA N, "Oh that foot hurts so bad, I could scream." CNA N continued cares retrieving a washcloth and washing Resident #2's upper torso. Resident #2 then stated, "I have been miserable all day, my leg hurts." CNA N continued performing cares. CNA N removed Resident #2's podus boots while Resident #2 continually stated, "Ow, ow, ow that hurts." When observation of cares were complete, Surveyor asked Resident #2 if he was able to rate his pain on a scale of 1-10. Resident #2 responded, "4." On 05/06/14 at 12:05 p.m., Surveyor interviewed LPN Q asking what time Resident #2 had his pain pills this morning. LPN Q responded, "At 10:30 a.m. I gave him his pain pills. I do not go in to his room a lot because he has a cat." On 05/07/14 at 7:45 a.m., Surveyor observed the DON perform Resident #2's pressure ulcer treatment to his left great toe and right heel. During the dressing change, Resident #2 winced and pulled away stating, "It hurts" when the DON touched his right heel. At the end of the dressing change, the DON asked Resident #2 if he was having pain, to which Resident #2 responded, "Some." The DON then asked Resident #2, "How does your foot feel?" To which Resident #2 responded, "About the same." On 05/06/14, during review of Resident #2's medical record, Surveyor was unable to locate a care plan that identified pain. On 05/07/14, Surveyor requested a copy of Resident #2's care plan that identified pain. On 05/07/14 at 10:00 a.m., Surveyor was provided with a copy of a document titled: "Problem: Potential for Comfort, Alteration" dated: 05/07/14. Review of Resident #2's document titled "Physician order [REDACTED]." [MEDICATION NAME] (Concentrate) 20 mg/ml (per milliliter) Solution does ordered: (0.5 ml/10mg) by mouth every 2 hours as needed FOR: Pain or shortness of breath. Administration Instructions: 10-20 mg every 2 hours." On 05/08/14 at 1:10 p.m., Surveyor interviewed Resident #2 asking if it helps with the pain when they give him a pain medication before personal cares and or changing his dressings. Resident #2 responded, "Yes."

Based on observation, interview and record review, the facility did not provide the necessary treatment and services to promote healing and prevent a new open area from developing for 1 of 3 residents reviewed with pressure ulcers. Resident #4 developed a facility acquired Stage 4 pressure ulcer. When the resident was identified as having a stage 3 pressure ulcer, the resident was utilizing a mattress used to treat up to a Stage 2 ulcer. The facility did not change the mattress to an air mattress for 11 days nor did they implement new interventions, during which time the Stage 3 pressure ulcer became worse and the resident developed an additional Stage 2 pressure ulcer. This is evidenced by: The facility's policy entitled "Skin Care Management," dated 01/12 states, "Purpose: It is the policy of this nursing home to provide skin care to residents that includes assessment, prevention of skin breakdown and management of pressure ulcers and other skin integrity concerns... 4. The Tissue Tolerance Protocol will be completed to determine which repositioning interval best reduces resident risk for developing pressure ulcers. The test will be completed upon new admission, readmission if a problem exists, annually, and if there is a significant change in the resident's condition...6. If potential skin breakdown is noted, the nurse will initiate appropriate preventive measures, add the interventions to the resident care plan and updates the C.N.A. assignment sheet as appropriate . The nurse will notify the dietary manager/dietician to initiate the appropriate nutrition interventions...10. The QAPI Skin Condition Management Report will be reviewed though PAR and through QAPI committee and any change in care, treatment, nutritional support, etc. will be determined and documented. The care plan will be reviewed and updated as appropriate by the interdisciplinary team." On 05/05/14 at 11:00 a.m., Surveyor reviewed Resident #4's medical record. The Braden Scale for Predicting Pressure Sore Risk, dated 11/27/13, scored the resident at a "12," high risk. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident #4 required total assistance of two staff with bed mobility, toilet use and bathing, extensive assistance of two staff with transfers and total assistance of one staff with personal hygiene and dressing. Resident #4 has impairment of both lower extremities and is frequently incontinent of bowel and bladder. Resident #4 had no history of pressure ulcers and was coded as at risk for developing pressure ulcers. Per the MDS, the resident had a pressure reducing device in the chair and bed and was on a turning/repositioning program. On 12/09/13, nurses' notes stated the following: 2:44 p.m., Skin problems: open area on coccyx 2.5 cm (centimeters). Red and swollen around open area. 2:46 p.m. stated, "Fax sent to:attending physician. Duoderm applied to open area that is located on coccyx 2.5 cm in length. 5:46 p.m. stated, Result: DC (DISCONTINUED) duoderm, apply [MEDICATION NAME] border, change Q (every) 2-3 days or when soiled. The "Skin Care Flow Sheets" contained the following documentation: 12/09/13 Wound type skin tear o/a (open area) coccyx 2.5 cm, exudate none, odor none, red, swollen. 12/10/13 Wound type skin tear 2.5 cm, exudate- sanguineous, odor- none, red, swollen. 12/15/13 Wound type skin tear 2.5 cm, exudate- sanguineous, odor- none, red, swollen. 12/19/13 Wound type skin tear 2.5 x 3 cm, exudate- scant serous, odor- none, red, swollen. The nurses' notes, dated 12/19/13 at 6:26 a.m., stated, "Procedure done: Area cleansed and [MEDICATION NAME] applied per MD orders. Procedure result: treatment effective. Action: continue to observe. Skin treatment: Receives application of dressings (with or without topical medications) other than to feet. Skin Problems: Resident has open area on coccyx. Full thickness of skin lost, exposing the SubQ tissues-presents as a deep crater (Pressure Stg 3). Length: 3. Width: 1 . Depth: 0.5 cm Tissue Type: Clean but not granulating. Wound Tissue: Pink. Drainage: No odor present light exudate. Note color of exudate: blood tinged. Surrounding tissue: warm. (One ulcer)." The nurse's note, dated 12/19/13 at 6:32 a.m., stated, "Skin treatment: Receives application of dressings (with or without topical medications) other than to feet. Action: continue to observe. Pressure Ulcer: Partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stg 2) Location: left lower buttock. Surface area: (L X W) 1.1 - 2.0 cm sq. (square) Tissue type: Closed wound. Tissue: Reddened. Drainage: No drainage noted, No odor present. Surrounding Tissue: warm. Pressure Ulcers Edges: Closed and nonproliferative. Skin Problems: abrasions." (Second ulcer) The "Skin Care Flow Sheets" contained the following documentation: 12/21/13 Wound type skin tear x 2, 2.5 x 3 cm (x 1) and 2 x 2 (x 1), exudate- scant, odor-none, reddened. (Resident has two open areas now). 12/24/13 Wound type skin tear, 2 1/2 x 1/2 x 1/2 cm, wound base-necrotic slough, exudate- small purulent, odor- foul, [DIAGNOSES REDACTED] surrounding tissue. [MEDICAL CONDITION] wound edges defined purple area. 12 25/13 Wound type skin tear 2 1/2 cm x 1/2 cm x 1/2 cm, exudate- small purulent, odor-foul, red and swollen. 12/28/13 Wound type O/A 3.5 cm x 1 cm, wound base- necrotic eschar, exudate- purulent, odor-foul, O/A-tunneling, blackened area, red, swollen. The nurses' notes, dated 12/28/13 at 2:01 p.m., stated, "Fax sent to: Attending physician. Open are on coccyx- outer tissue red and swollen, inner area 3.5 cm x 1 cm, necrotic eschar appears to be tunneling. Current orders to cleanse with n/s (normal saline), and cover with [MEDICATION NAME], change every 3 days." The nurses' notes, dated 12/30/14 at 2:44 p.m. stated, "Skin Problems: Continues with open area to coccyx that is being dressed q 3 days with [MEDICATION NAME] dressing - area has changed since writer last saw. Appears slightly larger, reported changes to DON (Director of Nursing) - states MD (Medical Doctor) wanted to continue with the [MEDICATION NAME] dressing. Writer did change this as old dressing was saturated with odorous tan drainage - area cleansed and re-dressed. DON states plans on obtaining air mattress for res (resident), also has new cushion in place." The "Skin Care Flow Sheet," dated 12/31/14, stated, "Wound type - skin tear, 3.5 cm x 1 cm, wound base- necrotic eschar, exudate-purulent, odor- none, Healing process - tunneling, red, swollen." The nurse's note, dated 12/31/13 at 1:26 p.m., stated, "Result: Air bed, change [MEDICATION NAME] Q (every) 2 days or when soiled." On 05/07/14 at 11:00 a.m., Surveyor observed Licensed Practical Nurse (LPN) V change a dressing on Resident #4's coccyx ulcer. LPN V stated she can't stage pressure ulcers but described the ulcer as "nickel size" and deep with no odor and pink edges. The last measurement recorded on the skin flow sheet, dated 05/01/14, described the pressure ulcer as a stage 4 pressure ulcer measuring 1.5 cm x 1 cm with granulation and small serous exudate. The ulcer had no odor and the wound margin was distinct with pink granulation. On 05/06/14 at 10:50 a.m., Surveyor interviewed the Director of Nursing (DON) related to the resident's pressure ulcers. The DON stated the pressure ulcer was acquired at the facility on 12/09/13. The surveyor and the DON reviewed the nurses' notes, dated 12/19/13, together, which staged the coccyx ulcer as a stage 3. The DON stated, "The ulcer started with partial skin loss that was denuded, she went to the wound clinic, the wound was debrided and became a stage 4." The DON stated the ulcer continues to be a stage 4 and is improving. Before developing the ulcer, the DON stated the resident used a "regular mattress" and a foam chair cushion. Surveyor questioned the DON as to what new interventions were put in place from 12/19/13 to 01/09/14, the DON said none. The DON stated the resident did not receive an air mattress and roho cushion until 01/09/14. Surveyor questioned if the facility had completed tissue tolerance tests assessments. The DON stated the facility does not complete them. On 05/06/14 at 1:15 p.m., Surveyor requested and received the information related to the Panacea Clinical Mattress which was provided to Resident #4 before developing pressure ulcers and when the resident had a stage 3 pressure ulcer on the coccyx and a newly developed stage 2 ulcer on the left buttocks. The manufacturer's information states, "May be appropriate through Stage II wounds. Mattress wound Stage ratings are general usage guidelines. Resident - specific assessment could alter your particular usage of these mattresses." Surveyor requested the information related to the foam chair cushion. No information was provided. On 05/12/14 at 2:50 p.m., Surveyor interviewed the DON related to conflicting information in the chart related to the date the air mattress was implemented. The DON reviewed the chart and stated the air mattress and roho cushion were added on 12/30/13. Surveyor questioned the DON what new interventions were added from 12/19/14 to 12/30/13, the DON stated, "None." The DON reviewed the skin flow sheet dated 12/21/13 and the nurses' notes of 12/19/13 documenting two pressure ulcers. The DON stated the resident had developed a second pressure ulcer on the left lower buttocks that has since healed.

Based on observation, interview and record review, it was determined the facility did not ensure supervision to prevent accidents for 1 of 9 sampled residents and did not ensure the residents' environment remained free of accident hazards in the beauty shop and in 2 of 3 storage areas. Resident #1 was transferred into her chair by facility staff and a facility staff member pushed her wheelchair into the hallway. Resident #1 fell out of the wheelchair because her safety seatbelt had not been fastened by facility staff. Resident #1 was transported to the emergency room for evaluation and treatment of [REDACTED]. One of one beauty shop was left unattended with chemicals unsecured. The facility was storing oxygen tanks in two of three storage areas where they were charging batteries and storing potentially flammable materials. This is evidenced by: 1. Resident #1 has a [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set ((MDS) dated [DATE] identifies the following: * Section B4 - cognition is severely impaired. * Section G1 - needs extensive assistance for transferring and requires total dependence for dressing, toileting and bathing. Resident #1's Resident Assessment Protocols (RAP) summary (dated 05/01/10) identified the following: * Is receiving medications that might contribute to falls. * Has loss of physical coordination. * Has weakness in legs. * Has had seven falls since 03/06/10. * Requires two assist with walker and gait belt to ambulate. * Has seatbelt in wheelchair and pressure alarm when in bed. * Has a history of many falls due to her attempted self-transfers and not being aware of safety and her surroundings. Since the seatbelt was added she has had only one fall. She also has a pressure alarm in her bed and a special mattress on bed to help prevent her trying to get up without assist while in bed. She has advanced Alzheimer's with dementia and is having some hypotension while standing. Resident #1's MDS dated [DATE] identifies the following: * Section-C1000 - cognition is severely impaired. * Section G0110 - needs limited assistance for transferring, dressing, hygiene and bathing. Resident #1's Physical Restraint MDS 2.0 RAP Module (dated 07/29/10 and 08/23/10) identifies the following: * History of a hip fracture * History of falls * Unstable acute condition * Delirium * Confusion * Poor safety awareness * Impulsivity * Cognitive loss * Unsteady gait * Resident attempts to self-transfer * Had seven falls since 03/06/10, but only once since the seatbelt was implemented. * Resident continues with seatbelt in wheelchair. Pressure alarm in bed with special mattress to help prevent her getting up without assist. Uses body pillows in bed also. The Physicians Order sheet (dated 03/30/10) identified the following. * Seatbelt while in wheelchair for safety. Resident #1's care plan states the following: * Safety equipment: Seatbelt while in wheelchair. The facility investigation report identified the following: Nurses' notes (dated 09/23/10) identified Resident #1 had a fall at 5:00 p.m. in the East hallway and received the following injuries: * Bruise measuring 2 cm (centimeter) long on left side of forehead above eyebrow. * Abrasion measuring 1 cm square under eye. * Abrasion under the nose measuring 0.75 cm in circumference. * Abrasion on the right elbow measuring 2 cm in length. * Abrasion under the right thumb measuring 0.25 cm in length. * Hematoma around the right eye. * Right and left hands are swollen. * Nosebleed Nurses' notes (dated 09/24/10) identified the following: * Follow-up, observed on floor, resident with several lacerations, right forehead, right elbow and left thumb, all intact. Social Worker H's written statement (dated 09/23/10) identified she was walking past the nurses' station and she saw staff running down the East hallway. Social Worker H saw Resident #1 on the floor. Social Worker H asked the staff why the seatbelt was not buckled. Certified Nursing Assistant (CNA) K responded, "I forgot, I'm so sorry, I just forgot." Registered Nurse (RN) T's written statement (dated 09/23/10) identified she saw someone fall forward onto the floor from the doorway in the hallway. RN T went to the scene and did an assessment. She said something about the status of her seatbelt. CNA K stated, "She didn't have it on. I didn't put it on." CNA L's written statement (dated 09/23/10) identified she and CNA K got Resident #1 up out of bed around 4:30-5:00 p.m. They put her in the wheelchair. CNA L did not recall who wheeled her out, right outside of her room. CNA L took another resident to the dining room. When she came back, Resident #1 was on the floor. RN G's written statement (dated 09/24/10) identified that on 09/23/10, she heard a thump, then got up and saw someone on the floor. Resident #1 was at her door entrance and the wheelchair was about 4 feet away. Resident #1 had a nosebleed and abrasion on her right eyebrow. She witnessed CNA K state "they or I just got her up and admitted not putting the belt on her." Licensed Practical Nurse (LPN) J's written statement (dated 09/24/10) identified she witnessed Resident #1 on the floor on 09/23/10. LPN J asked how she got out of the chair and CNA K stated she forgot to put the seatbelt on. CNA U's written statement (dated 09/24/10) identified that on 09/23/10, he witnessed someone falling and yelled to the other staff. He went down there and witnessed Resident #1 on the floor with her feet barely just inside of her bedroom doorway. Resident #1 was bleeding from her nose. CNA U remembers SW H saying something in regards to the seatbelt and remembers CNA K state CNA L and she forgot to put the seatbelt on her. A written statement from the Director of Nursing (DON) on 09/23/10 identified SW H came into her office and informed her of Resident #1's fall and that her seatbelt was not fastened on her. The DON identified which CNA was responsible for her and identified it was CNA K. The DON identified CNA K stated she forgot to put Resident #1's seatbelt on her. The DON informed CNA K she needs to send her home. The DON also informed her she holds the assignment sheets; "you are responsible to read the assignment sheets and follow the care plan." An interview with the DON on 11/08/10 at 11:55 a.m. with Surveyor identified CNA K did not follow the care plan of Resident #1 and did not attach her safety seatbelt which resulted in Resident #1 falling to the floor and receiving injury. An interview with the Nursing Home Administrator on 11/08/10 at 12:20 a.m. with Surveyor identified CNA K was the staff person responsible for Resident #1 and did not follow the care plan and did not attach the seatbelt which resulted in Resident #1 falling to the floor. She further stated CNA K had the care plan in her pocket and did not follow it. UNSECURED CHEMICALS 2. On 11/09/10 at 9:10 a.m., Surveyor observed the door to the beauty shop completely opened without staff in the area. This beauty shop is directly off the dining and activity room area. Surveyor entered the room and identified the following unsecured chemicals in the beauty shop: *All of these chemicals have a label instructing customers to keep out of reach of children. - One container of Century Q 256 Disinfectant - label states it can be harmful if swallowed. - One container of Hydrox Germicide and Disinfectant - label states it can cause severe eye and skin damage. - One container of Oster Professional Spray Disinfectant - label states it can be harmful by inhalation. May cause eye and skin irritation. - Three containers of Vita/E Ultra Hairspray - label states if inhaled it can be harmful or fatal. An interview with Beautician S on 11/09/10 at 9:15 a.m. by Surveyor identified she is an independent beautician who comes into the facility to style hair for the residents. She further stated this beauty shop is secured when she is not in the area. After this interview (at 9:17 a.m.), Beautician S left this area a second time, went to the attached assisted living facility and retrieved a resident to get her hair styled. Beautician S was gone for approximately five minutes (until 9:22 a.m.) leaving the room door open with the above chemicals unsecured. An interview with the Nursing Home Administrator on 11/09/10 at 12:30 p.m. by Surveyor identified the beauty shop is to be secured when staff are not in there or activity staff are not directly outside of the beauty shop in the activity area. OXYGEN STORAGE 3. During an environmental tour and interview with Maintenance Director P on 11/09/10 beginning at 7:15 a.m., Surveyor observed the following: 100 hall storage area - An oxygen tank (with a regulator attached) was stored directly under an area where two battery chargers for a mechanical lift were charging batteries. Maintenance Director P stated the oxygen tank with the regulator on it is not to be stored in this area. Maintenance Director P also stated the staff are not to store oxygen tanks with the regulators on them because they can leak. 200 hall storage area - Eight portable oxygen tanks were stored directly under an area where a telephone wiring board was present with bare wires exposed. Also in this storage area were two electric water heaters, a breaker box, four battery chargers (which were charging batteries), and a shelf with multiple potentially flammable paper products including 80 boxes of Kleenex, multiple boxes of gloves, plastic bags and cardboard boxes containing resident belongings. Maintenance Director P stated they moved these oxygen tanks from the designated oxygen room to this storage area about two years ago to better meet the needs of the residents. Maintenance Director P also stated it was his understanding the facility could store these tanks in this area as long as there was ventilation and they were secured. *Storing oxygen in areas where they are charging batteries could result in a fire or explosive situation.

Based on record review and interview, it was determined the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 15 originally sampled residents. Due to Resident #10's [DIAGNOSES REDACTED]. Resident #10 expressed to staff that she needed assistance with communication during her routine clinic visits to Eau Claire and was told by the facility that she needed to have family or volunteers assist with these appointments. On 09/20/10, Resident #10 had an appointment in Eau Claire. The facility did not provide any staff to accompany Resident #10 or assist with communication. During this transport, the van driver mistakenly took Resident #10 to St Paul, MN when Resident #10's appointment was at her Eau Claire, WI clinic. Resident #10 told the surveyor she tried to communicate with the driver that he was going the wrong way to no avail as he did not understand her. At the time of the incident, Resident #10 stated she was "very upset" as she knew she was going to miss her appointment in Eau Claire. Resident #10 said it has been "really stressful," she has been "worried" about this since the incident occurred, stating her "heart aches thinking about it." This is evidenced by: According to medical record review, Resident #10 has a [DIAGNOSES REDACTED]. She uses a homemade communication device, a piece of paper with the alphabet and a few word phrases for communication. Resident #10 has a difficult time speaking but is able to say words when she is given the time and is relaxed. During survey on 11/8/10 Resident #10 approached Surveyor at 3:10 p.m. and requested to talk. Activity Aide (AA) I was asked to interpret. Resident #10 was brought to her room and with the use of a communication device, hand gestures, with AA I interpreting, Surveyor questioning and clarifying and Resident #10 talking, Surveyor received the following information. -Resident #10 stated to Surveyor she was upset. At the time of the interview, she threw her head back and started to cry. After a short time, Resident #10 relaxed and continued to say she needs to go to Eau Claire every four months to get her medication pump replaced, pointing to her abdomen. -Resident #10 explained her mom had been coming with her to the appointments, but had recently been sick and is no longer able to come with Resident #10. She stated her dad is not able to come with her, neither is her sister as she works two jobs. -Resident #10 explained how she has had to go by herself the last few times and she is not able to communicate her needs. She stated she uses a communication board but not well, and needs someone to help her as she cannot point to the letters or phrases, needs to use someone's finger and then can guide their finger to the letters, due to her [DIAGNOSES REDACTED]. Per Resident #10, only a few staff at the facility can communicate with her and understand her. -Resident #10 explained how the last time she had an Eau Claire appointment, the van driver picked her up and took her to "the cities" (Minneapolis/St. Paul area). She knew he was going the wrong direction and she was "screaming" at the driver but the driver did not understand. She could not tell the driver. Resident #10 stated she was "very upset" as she knew she was going to miss her 4:00 p.m. appointment in Eau Claire. -During this interview, Resident #10 communicated that sometimes it takes three to four hours for the van ride. She stated, it is hard for her because she cannot tell anyone when she needs to go to the bathroom or needs something. According to Resident #10, it has been "real stressful," she has been feeling "stressed and worried about this" since the time when she went to the cities. Resident #10 also stated, her "heart aches thinking about it." -Resident #10 stated she told the social worker several times she needed someone with her and the social worker is a "liar, liar." When asked why she felt the social worker (Social Service Director H) lied to her, Resident #10 stated the social worker said she needed to find her own help to go with her and the facility would not pay a staff person to go with her. Resident #10 stated she felt another resident in the facility had a staff person go with them to an appointment and this was not fair. -Resident #10 stated she talked with the social worker right after the transportation incident on 09/20/10 and wanted to know why this happened and wanted a staff person to come with her for now on. The next day she went to her appointment, on 09/21/10, alone. -Resident #10 said not just anyone can come with to assist her, she needs someone that can understand and interpret. Resident #10's record was reviewed on 11/9/10 by Surveyor . The record indicates Resident #10 does go to a pain clinic in Eau Claire every four months. The pain clinic notes were reviewed. The 02/04/10 note stated, "The patient comes in today for routine DAS refill. Again the patient is here without any caretaker so she is very difficult to assess. Immediately upon bringing her back to the room it was obvious she did have to use the bathroom and we did assist her with that. There was no report from the nursing home with any changes of her medications or her [DIAGNOSES REDACTED]." On 09/20/10 the nurse's note stated, "SCHEDULED APPOINTMENT: Pain Clinic Eau Claire today at 4 PM for Baclofen pump refill. Appointment confirmed with Pain Clinic. TRANSPORTATION: Arranged with Handi-Lift earlier today. Pick-up at 2:15-2:30 PM. COMMENTS: Transport pick-up resident at around 2:15 PM, was given documents to bring. Driver called at about 3:50 PM telling that he's in Chestnut, MN. Called Handi lift and (name used) apologized for the big mistake. Accordg (according) to (name used), driver did not call office prior to pick-up here. Driver and (Resident #10) arrived at around 4:25 PM.....Arranged another appointment with Pain Clinic Eau Claire tomorrow Sept. 21, Tuesday at 2:15 PM. Pick-up here between 12:30 to 12:45 PM." Social Service Director H (SSD) was interviewed on 11/09/10 at 9:35 a.m. by Surveyor regarding the above interview with Resident #10, as this was not in the complaint file reviewed. SSD H said Resident #10 did come to her after this incident where she was sent to the cities and just wanted her to find out what happened. SSD H said Resident #10 was not upset and did not ask to have someone go with her to her appointments. SSD H said she was aware the resident's mom used to go but has been unable due to sickness. SSD H said she did follow up with the mix up regarding the transportation and the driver only looked at the address and took her to United as they had the same address as the pain clinic in Eau Claire. (The pain clinic in Eau Claire Resident #10 goes to is on Whipple Street, United Hospital is on Smith Avenue.) Surveyor asked SSD H if the facility had a policy or procedure regarding sending staff with residents that have needs to appointments. SSD H said, "No...usually a family member will go with them or a staff member can volunteer on their days off to go with a resident." SSD H said staff would not get paid to go with, they would have to go on their own time. SSD H said CNAs have gone with Resident #10 on their days off in the past. On June 23, 2009 a CNA volunteered her time to go with Resident #10. SSD H said no one went with Resident #10 on 09/21/10, the day immediately following the twin cities incident. Surveyor met with the NHA on 11/9/10 at 12:45 p.m. regarding Resident #10. Surveyor explained there was conflicting information regarding what SSD H said and what Surveyor thought Resident #10 was saying. Resident #10 said she had asked SSD H several times to have someone go with her and SSD H said she was not aware of this, even after the incident with the wrong transfer. SSD H denied Resident #10 being upset and denied her asking for staff to go with. NHA was also told Resident #10 used the words liar, liar regarding SSD H. NHA said possibly the activity aide would have met with Resident #10 and SSD H as the activity aide does real well understanding and interpreting for Resident #10. The NHA said the facility does not have a policy for transportation and she is checking with the corporate office to see about the over all transportation issue. Activity aide (AA) I was interviewed on 11/9/10 at 1:00 p.m. by Surveyor and asked if she recalled talking with SSD H with Resident #10 regarding the incident after the transportation to the cities. AA I said she was present and helped interpret for Resident #10. AA I said Resident #10 is very alert and oriented and knows what she needs and wants but has a hard time communicating her needs. AA I said she is pretty good about interpreting for Resident #10 as she gives her the time she needs and is able to help her relax so she can says words. AA I explained Resident #10 needs to guide someone else's finger on her communication board as she gets real shaky but she knows what she wants spelled. AA I said she has met with SSD H on other occasions with Resident #10 as well. Surveyor asked AA I what Resident #10 talked about with SSD H after the incorrect transport to the cities. AA I said Resident #10 was really upset about the van ride to the cities when she was supposed to be in Eau Claire and she asked SSD H to find out what happened. AA I said Resident #10 also discussed the need to have someone with her on these appointments as she can't tell staff if she has to go to the bathroom or if she needs something. AA I said SSD H has been made aware of the need for this several times in the past and she has also witnessed this. In the past, SSD H has said it needs to be a family member or a staff person could volunteer to go with Resident #10. With this last interview, SSD H said she could check into a volunteer from a church, someone from the community and named some organizations in the area that could possibly help out. AA I said Resident #10 got "real upset" and kept telling her "no" after each suggestion as she does not need someone to go to hold her hand; she needs someone that knows her, to interpret for her and understand her. AA I said this has been going on for quite awhile and Resident #10 gets so nervous and worried about not having someone with her that can interpret her needs. The NHA, DON and Resident #10 were asked to meet with Surveyors and on 11/9/10 at 1:30 p.m. so Surveyor could go over the interview with everyone to make sure Surveyor understood Resident #10 correctly. Resident #10 was explained the reason for the meeting was to ensure her needs were communicated and Surveyor accurately received the information from Resident on 11/8/10. Resident #10, with the assistance of the DON, was asked to correct Surveyor if anything was not accurate about the interview which we had the day before. Surveyor read the interview back to Resident #10. Resident #10 was able to give the "ok" sign with her fingers, state yes or communicate with the assistance of the DON using her communication device to answer. With each statement read Resident #10 acknowledged Surveyor was correct in the statement read. The NHA did correct one of the first statements read as the medication pump does not get "replaced" it gets "refilled." Resident #10 acknowledged the NHA was correct in making this statement. The only other statement that needed correction was the time it took to go to the Eau Claire appointment. Surveyor understood Resident #10 to state on 11/8/10 it sometimes takes three to four hours for the van ride. Resident #10 corrected this statement saying it takes a little over an hour each way. During the above group interview, the DON said she was not aware Resident #10 wanted someone to come with her or that someone was not with her and told Resident #10 she would make sure she had someone with her that could interpret for her. The DON ensured Resident #10 she would make sure Resident #10 approved of the staff that was going, someone Resident #10 knew could interpret for her. On 11/09/10, the NHA stated she is still waiting for directives from the corporate office to see if someone can go or not.